Provider Demographics
NPI:1902156565
Name:VICK, MELISSA L
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:L
Last Name:VICK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MELISSA
Other - Middle Name:LOSARIA
Other - Last Name:ROA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:908 N ELM ST
Mailing Address - Street 2:SUITE 306
Mailing Address - City:HINSDALE
Mailing Address - State:IL
Mailing Address - Zip Code:60521-3635
Mailing Address - Country:US
Mailing Address - Phone:630-323-5214
Mailing Address - Fax:
Practice Address - Street 1:908 N ELM ST
Practice Address - Street 2:SUITE 306
Practice Address - City:HINSDALE
Practice Address - State:IL
Practice Address - Zip Code:60521-3635
Practice Address - Country:US
Practice Address - Phone:630-323-5214
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-09-11
Last Update Date:2017-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085-003777363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant