Provider Demographics
NPI:1811585292
Name:SMITH, MELYNDA (APRN)
Entity Type:Individual
Prefix:
First Name:MELYNDA
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:819 ROSE LN
Mailing Address - Street 2:
Mailing Address - City:MATTESON
Mailing Address - State:IL
Mailing Address - Zip Code:60443-1934
Mailing Address - Country:US
Mailing Address - Phone:773-558-7448
Mailing Address - Fax:
Practice Address - Street 1:20 W KINZIE ST STE 17
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60654-6393
Practice Address - Country:US
Practice Address - Phone:855-490-5434
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-01
Last Update Date:2024-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209.022500363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily