Provider Demographics
NPI:1396453346
Name:HICKEY, MELINDA SUE (MSN, AGNP-C, CWON)
Entity type:Individual
Prefix:
First Name:MELINDA
Middle Name:SUE
Last Name:HICKEY
Suffix:
Gender:F
Credentials:MSN, AGNP-C, CWON
Other - Prefix:
Other - First Name:MELINDA
Other - Middle Name:SUE
Other - Last Name:GANGLOFF
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:355 S BRIDGE ST
Mailing Address - Street 2:
Mailing Address - City:BANNER
Mailing Address - State:IL
Mailing Address - Zip Code:61520-9307
Mailing Address - Country:US
Mailing Address - Phone:309-650-0615
Mailing Address - Fax:
Practice Address - Street 1:221 NE GLEN OAK AVE
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61636-0001
Practice Address - Country:US
Practice Address - Phone:309-678-2218
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-11-08
Last Update Date:2025-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209027429363LG0600X
ILAG09220121363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology