Provider Demographics
NPI:1053600932
Name:FITZGERALD, MELINDA RENEE (NP)
Entity type:Individual
Prefix:MRS
First Name:MELINDA
Middle Name:RENEE
Last Name:FITZGERALD
Suffix:
Gender:F
Credentials:NP
Other - Prefix:MS
Other - First Name:MELINDA
Other - Middle Name:
Other - Last Name:MARSHALL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:152 W. LINCOLN HIGHWAY
Mailing Address - Street 2:
Mailing Address - City:CHICAGO HEIGHTS
Mailing Address - State:IL
Mailing Address - Zip Code:60411-2619
Mailing Address - Country:US
Mailing Address - Phone:708-755-7359
Mailing Address - Fax:708-754-3071
Practice Address - Street 1:152 W. LINCOLN HIGHWAY
Practice Address - Street 2:
Practice Address - City:CHICAGO HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:60411-2619
Practice Address - Country:US
Practice Address - Phone:708-755-7359
Practice Address - Fax:708-754-3071
Is Sole Proprietor?:No
Enumeration Date:2011-03-31
Last Update Date:2012-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209008605363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL367830Medicare PIN