Provider Demographics
NPI:1093354243
Name:WISE, MELISSA (NP-C)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:
Last Name:WISE
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1101 N ALLEN ST
Mailing Address - Street 2:
Mailing Address - City:ROBINSON
Mailing Address - State:IL
Mailing Address - Zip Code:62454-1168
Mailing Address - Country:US
Mailing Address - Phone:618-546-5600
Mailing Address - Fax:618-546-2651
Practice Address - Street 1:1101 N ALLEN ST
Practice Address - Street 2:
Practice Address - City:ROBINSON
Practice Address - State:IL
Practice Address - Zip Code:62454-1168
Practice Address - Country:US
Practice Address - Phone:618-546-5600
Practice Address - Fax:618-546-2651
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-04
Last Update Date:2020-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209020617363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily