Provider Demographics
NPI:1467575092
Name:DYE, MELISSA J
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:J
Last Name:DYE
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 1:2805 N KNOXVILLE AVE
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61604-2869
Mailing Address - Country:US
Mailing Address - Phone:309-624-9400
Mailing Address - Fax:309-624-2280
Practice Address - Street 1:2805 N KNOXVILLE AVE
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61604-2869
Practice Address - Country:US
Practice Address - Phone:309-624-9400
Practice Address - Fax:309-624-2280
Is Sole Proprietor?:No
Enumeration Date:2007-04-09
Last Update Date:2010-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209-006545364SM0705X, 364S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364S00000XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse Specialist
No364SM0705XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistMedical-Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILP00397410OtherRR INDIVIDUAL #
IL809840OtherMEDICARE GROUP #
ILCA4079OtherRR GROUP #
ILK38691Medicare PIN