Provider Demographics
NPI:1720616444
Name:DORETTI, MELANIE (PA-C)
Entity Type:Individual
Prefix:
First Name:MELANIE
Middle Name:
Last Name:DORETTI
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2001 S CALIFORNIA AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60608-2486
Mailing Address - Country:US
Mailing Address - Phone:773-584-6200
Mailing Address - Fax:844-285-1003
Practice Address - Street 1:2001 S CALIFORNIA AVE STE 100
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60608-2486
Practice Address - Country:US
Practice Address - Phone:773-584-6200
Practice Address - Fax:844-285-1003
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-29
Last Update Date:2021-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085.007505363A00000X
IL085007505363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty