Provider Demographics
NPI:1073261715
Name:GILLESPIE, MELISSA MONIQUE
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:MONIQUE
Last Name:GILLESPIE
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 1:175 GREENWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:ORANGEBURG
Mailing Address - State:SC
Mailing Address - Zip Code:29115-2709
Mailing Address - Country:US
Mailing Address - Phone:803-333-4247
Mailing Address - Fax:
Practice Address - Street 1:175 GREENWOOD AVE
Practice Address - Street 2:
Practice Address - City:ORANGEBURG
Practice Address - State:SC
Practice Address - Zip Code:29115-2709
Practice Address - Country:US
Practice Address - Phone:803-333-4247
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-11
Last Update Date:2022-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1744P3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1744P3200XOther Service ProvidersSpecialistProsthetics Case Management