Provider Demographics
NPI:1346673910
Name:MIKOTA, MELISSA THIBAULT (APRN, FNP-BC)
Entity Type:Individual
Prefix:MRS
First Name:MELISSA
Middle Name:THIBAULT
Last Name:MIKOTA
Suffix:
Gender:F
Credentials:APRN, FNP-BC
Other - Prefix:MS
Other - First Name:MELISSA
Other - Middle Name:LYNN
Other - Last Name:THIBAULT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:ARNP
Mailing Address - Street 1:34344 N US HIGHWAY 45
Mailing Address - Street 2:
Mailing Address - City:THIRD LAKE
Mailing Address - State:IL
Mailing Address - Zip Code:60030-4031
Mailing Address - Country:US
Mailing Address - Phone:847-543-5440
Mailing Address - Fax:
Practice Address - Street 1:34344 N US HIGHWAY 45
Practice Address - Street 2:
Practice Address - City:THIRD LAKE
Practice Address - State:IL
Practice Address - Zip Code:60030-4031
Practice Address - Country:US
Practice Address - Phone:847-543-5440
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-08-18
Last Update Date:2022-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP133930363LF0000X
IL209010057363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1346673910Medicaid
WAG8923564OtherMEDICARE PTAN