Provider Demographics
NPI:1851995609
Name:GLASSCOCK, MELISSA (LPN)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:
Last Name:GLASSCOCK
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:MELISSA
Other - Middle Name:
Other - Last Name:BURLISON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:275 BLACKMAN HILL RD
Mailing Address - Street 2:
Mailing Address - City:HARRISBURG
Mailing Address - State:IL
Mailing Address - Zip Code:62946-5700
Mailing Address - Country:US
Mailing Address - Phone:618-314-2197
Mailing Address - Fax:
Practice Address - Street 1:11531 SUNDERLAND RD
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:IL
Practice Address - Zip Code:62959-8274
Practice Address - Country:US
Practice Address - Phone:618-964-5139
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-23
Last Update Date:2020-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL043.129363164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse