Provider Demographics
NPI:1750833356
Name:GLASS, MELISSA MARIE (APRN-FPA)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:MARIE
Last Name:GLASS
Suffix:
Gender:F
Credentials:APRN-FPA
Other - Prefix:
Other - First Name:MELISSA
Other - Middle Name:M
Other - Last Name:GLASS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:APRN-FPA
Mailing Address - Street 1:2124 HIGHWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:PEKIN
Mailing Address - State:IL
Mailing Address - Zip Code:61554-6328
Mailing Address - Country:US
Mailing Address - Phone:309-275-6363
Mailing Address - Fax:
Practice Address - Street 1:600 S 13TH ST
Practice Address - Street 2:
Practice Address - City:PEKIN
Practice Address - State:IL
Practice Address - Zip Code:61554-4936
Practice Address - Country:US
Practice Address - Phone:309-347-1151
Practice Address - Fax:309-347-6016
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-29
Last Update Date:2022-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL277.001921364SA2200X
IL277.001920363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
No364SA2200XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistAdult Health