Provider Demographics
NPI:1134740145
Name:VIZZA, MELISSA
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:
Last Name:VIZZA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1632 W CENTRAL RD
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON HEIGHTS
Mailing Address - State:IL
Mailing Address - Zip Code:60005-2407
Mailing Address - Country:US
Mailing Address - Phone:847-618-2500
Mailing Address - Fax:847-253-8474
Practice Address - Street 1:1632 W CENTRAL RD
Practice Address - Street 2:
Practice Address - City:ARLINGTON HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:60005-2407
Practice Address - Country:US
Practice Address - Phone:847-618-2500
Practice Address - Fax:847-253-8474
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-30
Last Update Date:2023-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085008275363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL085008275OtherSTATE LICENSE