Provider Demographics
NPI:1679114797
Name:DAVISSON, MELISSA (PA-C)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:
Last Name:DAVISSON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 68TH ST SE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49548-6927
Mailing Address - Country:US
Mailing Address - Phone:616-552-6139
Mailing Address - Fax:
Practice Address - Street 1:6505 CHERRY MEADOW DR SE
Practice Address - Street 2:
Practice Address - City:CALEDONIA
Practice Address - State:MI
Practice Address - Zip Code:49316-9484
Practice Address - Country:US
Practice Address - Phone:166-891-8770
Practice Address - Fax:616-891-3504
Is Sole Proprietor?:No
Enumeration Date:2019-09-30
Last Update Date:2021-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI56010094952084P0800X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant