Basic Information
Provider Information | |||||||||
NPI: | 1497397707 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | LOPEZ | ||||||||
FirstName: | MELISSA | ||||||||
MiddleName: | CARYN | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | NP | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | LEVIN | ||||||||
OtherFirstName: | MELISSA | ||||||||
OtherMiddleName: | C | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 901 MCCLINTOCK DR STE 202 | ||||||||
Address2: |   | ||||||||
City: | BURR RIDGE | ||||||||
State: | IL | ||||||||
PostalCode: | 605270872 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6306556748 | ||||||||
FaxNumber: | 6307344715 | ||||||||
Practice Location | |||||||||
Address1: | 2130 POINT BLVD STE 900 | ||||||||
Address2: |   | ||||||||
City: | ELGIN | ||||||||
State: | IL | ||||||||
PostalCode: | 601239214 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8882206432 | ||||||||
FaxNumber: | 6306544253 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/09/2019 | ||||||||
LastUpdateDate: | 10/09/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 209020173 | IL | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |   |
ID Information
ID | Type | State | Issuer | Description | 1235125717 | 01 | IL | GRP NPI | OTHER |