Provider Demographics
NPI:1235765249
Name:DIAL, MELINDA SUE (FNP)
Entity Type:Individual
Prefix:
First Name:MELINDA
Middle Name:SUE
Last Name:DIAL
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:419 S WALNUT ST
Mailing Address - Street 2:
Mailing Address - City:WAPELLA
Mailing Address - State:IL
Mailing Address - Zip Code:61777-2501
Mailing Address - Country:US
Mailing Address - Phone:217-871-8050
Mailing Address - Fax:
Practice Address - Street 1:702 W CHESTNUT ST
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IL
Practice Address - Zip Code:61701-2814
Practice Address - Country:US
Practice Address - Phone:618-877-4420
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-21
Last Update Date:2022-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209020879363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily