Provider Demographics
NPI:1689842361
Name:WILSON, MELISSA ANNE (ARNP)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:ANNE
Last Name:WILSON
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:MELISSA
Other - Middle Name:ANNE
Other - Last Name:AMOS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:ARNP
Mailing Address - Street 1:1007 S PEORIA AVE
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74120-4495
Mailing Address - Country:US
Mailing Address - Phone:918-587-1101
Mailing Address - Fax:918-592-7610
Practice Address - Street 1:1007 S PEORIA AVE
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74120-4495
Practice Address - Country:US
Practice Address - Phone:918-587-1101
Practice Address - Fax:918-592-7610
Is Sole Proprietor?:No
Enumeration Date:2008-02-14
Last Update Date:2022-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK90970363LA2200X, 363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200131880AOtherOKLAHOMA MEDICAID