Provider Demographics
NPI:1700085099
Name:MELLINGER, PATRICIA SULLIVAN (RN MSN APN/CNP)
Entity type:Individual
Prefix:MS
First Name:PATRICIA
Middle Name:SULLIVAN
Last Name:MELLINGER
Suffix:
Gender:F
Credentials:RN MSN APN/CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4405 WEAVER PKWY
Mailing Address - Street 2:
Mailing Address - City:WARRENVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60555-3269
Mailing Address - Country:US
Mailing Address - Phone:630-933-4950
Mailing Address - Fax:630-933-4958
Practice Address - Street 1:4405 WEAVER PKWY
Practice Address - Street 2:
Practice Address - City:WARRENVILLE
Practice Address - State:IL
Practice Address - Zip Code:60555-3269
Practice Address - Country:US
Practice Address - Phone:630-933-4950
Practice Address - Fax:630-933-4958
Is Sole Proprietor?:No
Enumeration Date:2007-07-16
Last Update Date:2018-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209003910363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL206147OtherMEDICARE PTAN (GROUP)
ILF00096658OtherMEDICARE PTAN (INDIVIDUAL)
IL041164899OtherMEDICAID