Provider Demographics
NPI:1114763737
Name:THEOBALD, MELISSA M (FNP)
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:M
Last Name:THEOBALD
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19014 N DAILY RD
Mailing Address - Street 2:
Mailing Address - City:PRINCEVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:61559-9312
Mailing Address - Country:US
Mailing Address - Phone:309-231-2050
Mailing Address - Fax:
Practice Address - Street 1:3626 N SHERIDAN RD
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61604-1401
Practice Address - Country:US
Practice Address - Phone:309-308-5100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-03
Last Update Date:2024-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041362793163W00000X
IL209030474363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse