Provider Demographics
NPI:1710309364
Name:WILKES, MELISSA
Entity Type:Individual
Prefix:MS
First Name:MELISSA
Middle Name:
Last Name:WILKES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:711 CLEVELAND AVE
Mailing Address - Street 2:
Mailing Address - City:WILDWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:34785-3502
Mailing Address - Country:US
Mailing Address - Phone:352-399-6862
Mailing Address - Fax:352-399-6863
Practice Address - Street 1:711 CLEVELAND AVE
Practice Address - Street 2:
Practice Address - City:WILDWOOD
Practice Address - State:FL
Practice Address - Zip Code:34785-3502
Practice Address - Country:US
Practice Address - Phone:352-399-6862
Practice Address - Fax:352-399-6863
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-16
Last Update Date:2016-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9263261QA0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA0600XAmbulatory Health Care FacilitiesClinic/CenterAdult Day Care