Provider Demographics
NPI:1992354799
Name:KEITH, MELISSA L (DNP)
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:L
Last Name:KEITH
Suffix:
Gender:F
Credentials:DNP
Other - Prefix:
Other - First Name:MELISSA
Other - Middle Name:L
Other - Last Name:BRADLEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:500 W RIVER DR
Mailing Address - Street 2:
Mailing Address - City:DAVENPORT
Mailing Address - State:IA
Mailing Address - Zip Code:52801-1014
Mailing Address - Country:US
Mailing Address - Phone:563-336-3000
Mailing Address - Fax:563-336-3125
Practice Address - Street 1:708 15TH AVE
Practice Address - Street 2:
Practice Address - City:EAST MOLINE
Practice Address - State:IL
Practice Address - Zip Code:61244-2134
Practice Address - Country:US
Practice Address - Phone:563-336-3000
Practice Address - Fax:563-336-3212
Is Sole Proprietor?:No
Enumeration Date:2019-09-05
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAA155669363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
IAPENDINGMedicaid
ILPENDINGMedicaid