Provider Demographics
NPI:1760929616
Name:WIESE, MELISA GREEN (APRN, NP-C)
Entity Type:Individual
Prefix:
First Name:MELISA
Middle Name:GREEN
Last Name:WIESE
Suffix:
Gender:F
Credentials:APRN, NP-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 E MCBEE AVE FL 4
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29601-2842
Mailing Address - Country:US
Mailing Address - Phone:864-522-8603
Mailing Address - Fax:
Practice Address - Street 1:905 VERDAE BLVD STE 202
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29607-4098
Practice Address - Country:US
Practice Address - Phone:864-676-1072
Practice Address - Fax:864-522-2105
Is Sole Proprietor?:No
Enumeration Date:2017-01-30
Last Update Date:2021-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC20615363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCNP4342Medicaid