Provider Demographics
NPI:1174045462
Name:MELENDEZ, KINSEY
Entity Type:Individual
Prefix:
First Name:KINSEY
Middle Name:
Last Name:MELENDEZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1890 SILVER CROSS BLVD.
Mailing Address - Street 2:SUITE 275
Mailing Address - City:NEW LENOX
Mailing Address - State:IL
Mailing Address - Zip Code:60451
Mailing Address - Country:US
Mailing Address - Phone:815-300-7764
Mailing Address - Fax:
Practice Address - Street 1:1890 SILVER CROSS BLVD.
Practice Address - Street 2:SUITE 275
Practice Address - City:NEW LENOX
Practice Address - State:IL
Practice Address - Zip Code:60451
Practice Address - Country:US
Practice Address - Phone:815-300-7764
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-09
Last Update Date:2024-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041400850163W00000X
IL209.016741363LA2100X, 363LA2200X, 363LG0600X, 363LC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LC0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerCritical Care Medicine
No163W00000XNursing Service ProvidersRegistered Nurse
No363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology