Provider Demographics
NPI:1770986010
Name:BANAL, MELANIE L (NP-C)
Entity type:Individual
Prefix:
First Name:MELANIE
Middle Name:L
Last Name:BANAL
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14160 JAMESTOWN RD
Mailing Address - Street 2:
Mailing Address - City:BREESE
Mailing Address - State:IL
Mailing Address - Zip Code:62230-3694
Mailing Address - Country:US
Mailing Address - Phone:618-526-7154
Mailing Address - Fax:618-526-8248
Practice Address - Street 1:14160 JAMESTOWN RD
Practice Address - Street 2:
Practice Address - City:BREESE
Practice Address - State:IL
Practice Address - Zip Code:62230-3694
Practice Address - Country:US
Practice Address - Phone:618-526-7154
Practice Address - Fax:618-526-8248
Is Sole Proprietor?:No
Enumeration Date:2014-10-01
Last Update Date:2022-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209011871363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner