Provider Demographics
NPI:1689979841
Name:WILSON, MELISSA (APRN)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2605 KENTUCKY AVE
Mailing Address - Street 2:SUITE 306
Mailing Address - City:PADUCAH
Mailing Address - State:KY
Mailing Address - Zip Code:42003-3800
Mailing Address - Country:US
Mailing Address - Phone:270-415-7653
Mailing Address - Fax:270-575-8359
Practice Address - Street 1:2601 KENTUCKY AVE
Practice Address - Street 2:SUITE 102
Practice Address - City:PADUCAH
Practice Address - State:KY
Practice Address - Zip Code:42003-3817
Practice Address - Country:US
Practice Address - Phone:270-575-8462
Practice Address - Fax:270-443-0235
Is Sole Proprietor?:No
Enumeration Date:2011-01-20
Last Update Date:2020-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3006845363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100151190Medicaid