Provider Demographics
NPI:1164455127
Name:FRALEY, MELISSA (PA)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:
Last Name:FRALEY
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:MELISSA
Other - Middle Name:
Other - Last Name:SHRYOCK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1001 MAIN ST
Mailing Address - Street 2:STE 300
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61606-2036
Mailing Address - Country:US
Mailing Address - Phone:309-495-0260
Mailing Address - Fax:309-495-0276
Practice Address - Street 1:675 N SAINT CLAIR ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611-5975
Practice Address - Country:US
Practice Address - Phone:312-695-9797
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-09
Last Update Date:2018-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085002046363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
KO9805Medicare ID - Type Unspecified