Provider Demographics
NPI:1700836509
Name:MCCLINTIC, MELISA S (APRN, CNP)
Entity type:Individual
Prefix:
First Name:MELISA
Middle Name:S
Last Name:MCCLINTIC
Suffix:
Gender:F
Credentials:APRN, CNP
Other - Prefix:
Other - First Name:MELISA
Other - Middle Name:S
Other - Last Name:MUNDWILER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1051 W SOUTH ST
Mailing Address - Street 2:
Mailing Address - City:KEWANEE
Mailing Address - State:IL
Mailing Address - Zip Code:61443-8354
Mailing Address - Country:US
Mailing Address - Phone:309-852-7700
Mailing Address - Fax:309-852-7764
Practice Address - Street 1:1051 W SOUTH ST
Practice Address - Street 2:
Practice Address - City:KEWANEE
Practice Address - State:IL
Practice Address - Zip Code:61443-8354
Practice Address - Country:US
Practice Address - Phone:309-852-7700
Practice Address - Fax:309-852-7764
Is Sole Proprietor?:No
Enumeration Date:2006-05-11
Last Update Date:2025-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209002117363LF0000X
IL209-002117363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILP75776Medicare UPIN
IL208668Medicare PIN