Provider Demographics
NPI:1124855788
Name:TRADER, MELISSA (RN)
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:
Last Name:TRADER
Suffix:
Gender:
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23422 COVERED BRIDGE RD
Mailing Address - Street 2:
Mailing Address - City:ATHENS
Mailing Address - State:IL
Mailing Address - Zip Code:62613-7606
Mailing Address - Country:US
Mailing Address - Phone:217-341-9093
Mailing Address - Fax:
Practice Address - Street 1:1900 E MAIN ST
Practice Address - Street 2:
Practice Address - City:DANVILLE
Practice Address - State:IL
Practice Address - Zip Code:61832-5100
Practice Address - Country:US
Practice Address - Phone:217-544-3000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-17
Last Update Date:2025-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041-340104163W00000X
IL209031506363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse