Provider Demographics
NPI:1659748259
Name:WILSON, MELISSA JOYE (NP)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:JOYE
Last Name:WILSON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:MELISSA
Other - Middle Name:JOYE
Other - Last Name:TOOKE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:100 MICHIGAN ST NE # MC-845
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-2560
Mailing Address - Country:US
Mailing Address - Phone:616-391-8242
Mailing Address - Fax:616-391-8317
Practice Address - Street 1:418 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:LAKEVIEW
Practice Address - State:MI
Practice Address - Zip Code:48850-7102
Practice Address - Country:US
Practice Address - Phone:989-352-6474
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-08-31
Last Update Date:2023-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704271637363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIM74460Medicare PIN