Provider Demographics
NPI:1073883468
Name:WILSON, MELISSA (LPN, OTC, CPED, BOCO)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:LPN, OTC, CPED, BOCO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1701 WESTCHESTER DRIVE
Mailing Address - Street 2:SUITE 850
Mailing Address - City:HIGH POINT
Mailing Address - State:NC
Mailing Address - Zip Code:27262-7254
Mailing Address - Country:US
Mailing Address - Phone:336-802-2536
Mailing Address - Fax:336-802-2534
Practice Address - Street 1:611 N LINDSAY ST
Practice Address - Street 2:SUITE 200
Practice Address - City:HIGH POINT
Practice Address - State:NC
Practice Address - Zip Code:27262-4300
Practice Address - Country:US
Practice Address - Phone:336-802-2250
Practice Address - Fax:336-802-2251
Is Sole Proprietor?:No
Enumeration Date:2012-01-03
Last Update Date:2015-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC034220164W00000X
BOCO C50277222Z00000X
ABC CPED 0855224L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotist
No164W00000XNursing Service ProvidersLicensed Practical Nurse
No224L00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPedorthist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7795543Medicaid