Provider Demographics
NPI:1497397707
Name:LOPEZ, MELISSA CARYN (NP)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:CARYN
Last Name:LOPEZ
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:MELISSA
Other - Middle Name:C
Other - Last Name:LEVIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:901 MCCLINTOCK DR STE 202
Mailing Address - Street 2:
Mailing Address - City:BURR RIDGE
Mailing Address - State:IL
Mailing Address - Zip Code:60527-0872
Mailing Address - Country:US
Mailing Address - Phone:630-655-6748
Mailing Address - Fax:630-734-4715
Practice Address - Street 1:2130 POINT BLVD STE 900
Practice Address - Street 2:
Practice Address - City:ELGIN
Practice Address - State:IL
Practice Address - Zip Code:60123-9214
Practice Address - Country:US
Practice Address - Phone:888-220-6432
Practice Address - Fax:630-654-4253
Is Sole Proprietor?:No
Enumeration Date:2019-10-09
Last Update Date:2019-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209020173363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1235125717OtherGRP NPI