Provider Demographics
NPI:1619569258
Name:WILKEY, MELISSA TIDWELL (CPNP)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:TIDWELL
Last Name:WILKEY
Suffix:
Gender:F
Credentials:CPNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2601 E MAIN ST STE 200
Mailing Address - Street 2:
Mailing Address - City:VENTURA
Mailing Address - State:CA
Mailing Address - Zip Code:93003-2801
Mailing Address - Country:US
Mailing Address - Phone:805-643-7500
Mailing Address - Fax:805-643-7510
Practice Address - Street 1:2601 E MAIN ST STE 200
Practice Address - Street 2:
Practice Address - City:VENTURA
Practice Address - State:CA
Practice Address - Zip Code:93003-2801
Practice Address - Country:US
Practice Address - Phone:805-643-7500
Practice Address - Fax:805-643-7510
Is Sole Proprietor?:No
Enumeration Date:2021-02-05
Last Update Date:2021-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95016601363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics