Provider Demographics
NPI:1902342918
Name:HATHAWAY, MELANIE ANN
Entity Type:Individual
Prefix:
First Name:MELANIE
Middle Name:ANN
Last Name:HATHAWAY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:206 S JEFFERSON ST
Mailing Address - Street 2:UNIT 2
Mailing Address - City:LOCKPORT
Mailing Address - State:IL
Mailing Address - Zip Code:60441-2934
Mailing Address - Country:US
Mailing Address - Phone:331-245-9096
Mailing Address - Fax:
Practice Address - Street 1:206 S JEFFERSON ST
Practice Address - Street 2:UNIT 2
Practice Address - City:LOCKPORT
Practice Address - State:IL
Practice Address - Zip Code:60441-2934
Practice Address - Country:US
Practice Address - Phone:331-245-9096
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-13
Last Update Date:2017-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041445205163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse