Provider Demographics
NPI:1972042570
Name:MEKELBURG, BREANNE NICOLE (LPN)
Entity Type:Individual
Prefix:MRS
First Name:BREANNE
Middle Name:NICOLE
Last Name:MEKELBURG
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:317 TEXAS AVE
Mailing Address - Street 2:
Mailing Address - City:CARTERVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62918-1430
Mailing Address - Country:US
Mailing Address - Phone:618-203-3954
Mailing Address - Fax:
Practice Address - Street 1:317 TEXAS AVE
Practice Address - Street 2:
Practice Address - City:CARTERVILLE
Practice Address - State:IL
Practice Address - Zip Code:62918-1430
Practice Address - Country:US
Practice Address - Phone:618-203-3954
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-02-15
Last Update Date:2017-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL043118022164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL164W00000XMedicaid