1003919382 NPI number — MELISSA TERHARK C.R.N.A

Table of content: MELISSA TERHARK C.R.N.A (NPI 1003919382)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1003919382 NPI number — MELISSA TERHARK C.R.N.A

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
TERHARK
Provider First Name:
MELISSA
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
C.R.N.A
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1003919382
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/03/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2814 E 2525TH RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MARSEILLES
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
61341-9570
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
309-453-9350
Provider Business Mailing Address Fax Number:
309-692-2538

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8600 NORTH STATE ROUTE 91
Provider Second Line Business Practice Location Address:
SUITE #250
Provider Business Practice Location Address City Name:
PEORIA
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
61615
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
309-692-5394
Provider Business Practice Location Address Fax Number:
309-692-2538
Provider Enumeration Date:
09/05/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 367500000X , with the licence number:  041253749 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 367500000X , with the licence number: 209.005184 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 105390700 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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