Provider Demographics
NPI:1679516561
Name:HENDERSON, MELINDA (C-FNP)
Entity Type:Individual
Prefix:
First Name:MELINDA
Middle Name:
Last Name:HENDERSON
Suffix:
Gender:F
Credentials:C-FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5100 RELIABLE PARKWAY
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60686-0001
Mailing Address - Country:US
Mailing Address - Phone:309-692-6088
Mailing Address - Fax:
Practice Address - Street 1:7801 N KNOXVILLE AVE
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61614-2076
Practice Address - Country:US
Practice Address - Phone:309-692-6088
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILIL01Q9OtherJOHN DEERE
IL073083OtherHEALTH ALLIANCE
IL472310OtherHEALTHLINK
IL7215059OtherBCBS PPO