Provider Demographics
NPI:1629021357
Name:WILLIS, MELISSA MAE (FNP)
Entity Type:Individual
Prefix:MRS
First Name:MELISSA
Middle Name:MAE
Last Name:WILLIS
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2209 JOHN R WOODEN DR
Mailing Address - Street 2:
Mailing Address - City:MARTINSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46151-1840
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2209 JOHN R WOODEN DR
Practice Address - Street 2:
Practice Address - City:MARTINSVILLE
Practice Address - State:IN
Practice Address - Zip Code:46151-1840
Practice Address - Country:US
Practice Address - Phone:765-342-8383
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-17
Last Update Date:2020-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71000581363L00000X
IN71000581A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200202970Medicaid
INS84009Medicare UPIN
IN940410L7Medicare PIN