Provider Demographics
NPI:1639681117
Name:GARMON, MELISSA RENEE (PA)
Entity Type:Individual
Prefix:MRS
First Name:MELISSA
Middle Name:RENEE
Last Name:GARMON
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:MELISSA
Other - Middle Name:RENEE
Other - Last Name:SHERRILL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:101 FAIRVIEW AVE
Mailing Address - Street 2:
Mailing Address - City:BARTONVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:61607-2309
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5114 N GLEN PARK PLACE RD
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61614-4686
Practice Address - Country:US
Practice Address - Phone:309-683-5600
Practice Address - Fax:309-683-5607
Is Sole Proprietor?:No
Enumeration Date:2017-10-24
Last Update Date:2017-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085006416363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant