Provider Demographics
NPI:1245069640
Name:BURRIS, MELINDA LAURA
Entity type:Individual
Prefix:
First Name:MELINDA
Middle Name:LAURA
Last Name:BURRIS
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 1:1000 S CLARK ST UNIT 1610
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60605-2194
Mailing Address - Country:US
Mailing Address - Phone:765-465-9279
Mailing Address - Fax:
Practice Address - Street 1:2118 N HALSTED ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60614-0758
Practice Address - Country:US
Practice Address - Phone:773-482-0020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-01
Last Update Date:2024-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041476177163W00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program