Provider Demographics
NPI:1619310141
Name:MELLEN, HEIDI GABRIEL (RN)
Entity Type:Individual
Prefix:MRS
First Name:HEIDI
Middle Name:GABRIEL
Last Name:MELLEN
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:730 FENVIEW CIR
Mailing Address - Street 2:
Mailing Address - City:ALGONQUIN
Mailing Address - State:IL
Mailing Address - Zip Code:60102-6801
Mailing Address - Country:US
Mailing Address - Phone:425-681-0811
Mailing Address - Fax:
Practice Address - Street 1:730 FENVIEW CIR
Practice Address - Street 2:
Practice Address - City:ALGONQUIN
Practice Address - State:IL
Practice Address - Zip Code:60102-6801
Practice Address - Country:US
Practice Address - Phone:425-681-0811
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-04-15
Last Update Date:2013-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041.204865163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL633297173Medicaid