Provider Demographics
NPI:1407357148
Name:ORTEGA, MELISSA EWERT (APN)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:EWERT
Last Name:ORTEGA
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:401 N WALL ST STE 208
Mailing Address - Street 2:
Mailing Address - City:KANKAKEE
Mailing Address - State:IL
Mailing Address - Zip Code:60901-2949
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:990 N KINZIE AVE
Practice Address - Street 2:
Practice Address - City:BRADLEY
Practice Address - State:IL
Practice Address - Zip Code:60915-1233
Practice Address - Country:US
Practice Address - Phone:815-935-7256
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-27
Last Update Date:2018-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209017280363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily