Provider Demographics
NPI:1811062623
Name:RICHARDSON, MELONIE M (NP)
Entity type:Individual
Prefix:MRS
First Name:MELONIE
Middle Name:M
Last Name:RICHARDSON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:819 BLOOMINGTON RD
Mailing Address - Street 2:
Mailing Address - City:CHAMPAIGN
Mailing Address - State:IL
Mailing Address - Zip Code:61820-2101
Mailing Address - Country:US
Mailing Address - Phone:217-356-1558
Mailing Address - Fax:217-366-0160
Practice Address - Street 1:819 BLOOMINGTON RD
Practice Address - Street 2:
Practice Address - City:CHAMPAIGN
Practice Address - State:IL
Practice Address - Zip Code:61820-2101
Practice Address - Country:US
Practice Address - Phone:217-356-1558
Practice Address - Fax:217-366-0160
Is Sole Proprietor?:No
Enumeration Date:2006-11-21
Last Update Date:2024-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209004802363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL6447860011Medicare NSC
Q19128Medicare UPIN
ILK12619Medicare UPIN
ILIL3270120Medicare PIN