Provider Demographics
NPI:1134632516
Name:HOUSE, MELISSA RAY (APRN, CNM, WHNP-BC)
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:RAY
Last Name:HOUSE
Suffix:
Gender:F
Credentials:APRN, CNM, WHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:900 N WESTMORELAND RD STE 112
Mailing Address - Street 2:
Mailing Address - City:LAKE FOREST
Mailing Address - State:IL
Mailing Address - Zip Code:60045-1674
Mailing Address - Country:US
Mailing Address - Phone:847-535-7057
Mailing Address - Fax:847-615-2260
Practice Address - Street 1:900 N WESTMORELAND RD STE 112
Practice Address - Street 2:
Practice Address - City:LAKE FOREST
Practice Address - State:IL
Practice Address - Zip Code:60045-1674
Practice Address - Country:US
Practice Address - Phone:847-535-7057
Practice Address - Fax:847-615-2260
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-08
Last Update Date:2022-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209016864176B00000X, 367A00000X
IL277001224367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
No176B00000XOther Service ProvidersMidwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILPENDINGMedicaid