Provider Demographics
NPI:1134135817
Name:WILSON, MELISSA
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:
Last Name:WILSON
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 1:1 BROAD STREET PLZ
Mailing Address - Street 2:PO BOX 357
Mailing Address - City:GLENS FALLS
Mailing Address - State:NY
Mailing Address - Zip Code:12801-4390
Mailing Address - Country:US
Mailing Address - Phone:518-761-0300
Mailing Address - Fax:518-745-1378
Practice Address - Street 1:3767 MAIN ST
Practice Address - Street 2:
Practice Address - City:WARRENSBURG
Practice Address - State:NY
Practice Address - Zip Code:12885-1837
Practice Address - Country:US
Practice Address - Phone:518-623-2844
Practice Address - Fax:518-623-3416
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY400639363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYQ14059Medicare UPIN
NYRA1521Medicare ID - Type Unspecified