Provider Demographics
NPI:1609470483
Name:CRANE, MELISSA FERN (LPN)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:FERN
Last Name:CRANE
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:MELISSA
Other - Middle Name:FERN
Other - Last Name:CRANE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LPN
Mailing Address - Street 1:202 N POPLAR ST
Mailing Address - Street 2:
Mailing Address - City:DE SOTO
Mailing Address - State:IL
Mailing Address - Zip Code:62924-1202
Mailing Address - Country:US
Mailing Address - Phone:618-967-5250
Mailing Address - Fax:
Practice Address - Street 1:11531 SUNDERLAND RD
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:IL
Practice Address - Zip Code:62959-8274
Practice Address - Country:US
Practice Address - Phone:618-964-5139
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-23
Last Update Date:2020-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL043.119883164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse