Provider Demographics
NPI:1285045013
Name:LANGE, MELINDA LUCILLE (ADVANCED PRACTICENUR)
Entity Type:Individual
Prefix:MISS
First Name:MELINDA
Middle Name:LUCILLE
Last Name:LANGE
Suffix:
Gender:F
Credentials:ADVANCED PRACTICENUR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:104 BARBARA ST
Mailing Address - Street 2:
Mailing Address - City:EAST PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61611-4591
Mailing Address - Country:US
Mailing Address - Phone:309-258-1783
Mailing Address - Fax:309-282-1609
Practice Address - Street 1:530 NE GLEN OAK AVE
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61637-0001
Practice Address - Country:US
Practice Address - Phone:309-655-2000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-14
Last Update Date:2014-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209011332364SA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SA2200XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1043260482Medicare UPIN