Provider Demographics
NPI:1982093738
Name:HETZEL, MELISSA LOUISE (RN, CCM)
Entity Type:Individual
Prefix:MRS
First Name:MELISSA
Middle Name:LOUISE
Last Name:HETZEL
Suffix:
Gender:F
Credentials:RN, CCM
Other - Prefix:MS
Other - First Name:MELISSA
Other - Middle Name:LOUISE
Other - Last Name:WALL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:1340 S DAMEN AVE
Mailing Address - Street 2:SUITE 400
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60608-1169
Mailing Address - Country:US
Mailing Address - Phone:800-530-9200
Mailing Address - Fax:855-582-6563
Practice Address - Street 1:1340 S DAMEN AVE
Practice Address - Street 2:SUITE 400
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60608-1169
Practice Address - Country:US
Practice Address - Phone:800-530-9200
Practice Address - Fax:855-582-6563
Is Sole Proprietor?:No
Enumeration Date:2015-01-16
Last Update Date:2015-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28125209A163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse