Provider Demographics
NPI:1346705993
Name:WALLIS, MELISSA KAY (AGNP)
Entity Type:Individual
Prefix:MS
First Name:MELISSA
Middle Name:KAY
Last Name:WALLIS
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Gender:F
Credentials:AGNP
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Mailing Address - Street 1:660 S EUCLID AVE
Mailing Address - Street 2:CB 8057
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63110-1010
Mailing Address - Country:US
Mailing Address - Phone:314-747-6174
Mailing Address - Fax:314-362-2107
Practice Address - Street 1:4921 PARKVIEW PL
Practice Address - Street 2:DIV NEURO SURG, STE 6B/6C
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63110-1032
Practice Address - Country:US
Practice Address - Phone:314-362-3577
Practice Address - Fax:314-362-2107
Is Sole Proprietor?:No
Enumeration Date:2019-02-07
Last Update Date:2021-11-15
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Provider Licenses
StateLicense IDTaxonomies
MO2019005399363L00000X
MO2013023808363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO420070582Medicaid