Provider Demographics
NPI:1720410004
Name:WILSON, MELISSA (RN)
Entity Type:Individual
Prefix:MS
First Name:MELISSA
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:794 MIDWOOD ST APT 1D
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11203-1407
Mailing Address - Country:US
Mailing Address - Phone:646-359-1554
Mailing Address - Fax:
Practice Address - Street 1:9131 QUEENS BLVD
Practice Address - Street 2:SUITE 604
Practice Address - City:ELMHURST
Practice Address - State:NY
Practice Address - Zip Code:11373-5555
Practice Address - Country:US
Practice Address - Phone:646-359-1554
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-08-08
Last Update Date:2013-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY666763163W00000X, 163WC0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC0400XNursing Service ProvidersRegistered NurseCase Management
No163W00000XNursing Service ProvidersRegistered Nurse