Provider Demographics
NPI:1033530548
Name:KOEHLER, MELISSA
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:
Last Name:KOEHLER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MELISSA
Other - Middle Name:
Other - Last Name:SOLOMON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:APN
Mailing Address - Street 1:2323 CENTRAL ST
Mailing Address - Street 2:APT 3W
Mailing Address - City:EVANSTON
Mailing Address - State:IL
Mailing Address - Zip Code:60201-5736
Mailing Address - Country:US
Mailing Address - Phone:847-826-0903
Mailing Address - Fax:
Practice Address - Street 1:572 LINCOLN AVE
Practice Address - Street 2:SUITE #3
Practice Address - City:WINNETKA
Practice Address - State:IL
Practice Address - Zip Code:60093-2308
Practice Address - Country:US
Practice Address - Phone:847-501-4040
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-12-31
Last Update Date:2013-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041.415962163W00000X
IL209.011071363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL209.011071OtherAPN LICENSE
IL041.415962OtherRN LICENSE