Provider Demographics
NPI:1396159844
Name:EASLEY, MELISSA (LMT/CMMP/CNA)
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:
Last Name:EASLEY
Suffix:
Gender:F
Credentials:LMT/CMMP/CNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:714 N 9TH AVE
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:IL
Mailing Address - Zip Code:61520-1435
Mailing Address - Country:US
Mailing Address - Phone:309-338-3953
Mailing Address - Fax:
Practice Address - Street 1:25 WHITE CT
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:IL
Practice Address - Zip Code:61520-2626
Practice Address - Country:US
Practice Address - Phone:309-338-3953
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-12
Last Update Date:2014-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL227003112225700000X
IL376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
No376K00000XNursing Service Related ProvidersNurse's Aide