Provider Demographics
NPI:1891245981
Name:FANNON-WISNER, MELISSA LYNN (CRNP)
Entity Type:Individual
Prefix:MRS
First Name:MELISSA
Middle Name:LYNN
Last Name:FANNON-WISNER
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:MISS
Other - First Name:MELISSA
Other - Middle Name:LYNN
Other - Last Name:FANNON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CRNP
Mailing Address - Street 1:120 CAMPUS DR
Mailing Address - Street 2:
Mailing Address - City:MARTINSBURG
Mailing Address - State:WV
Mailing Address - Zip Code:25404-7552
Mailing Address - Country:US
Mailing Address - Phone:410-205-0444
Mailing Address - Fax:
Practice Address - Street 1:101 MARCLEY DR
Practice Address - Street 2:
Practice Address - City:MARTINSBURG
Practice Address - State:WV
Practice Address - Zip Code:25401-2977
Practice Address - Country:US
Practice Address - Phone:304-263-8911
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-10-12
Last Update Date:2022-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024185033363LF0000X
PASP016840363LF0000X
MDAC003394363LF0000X
MDR184523363LF0000X
WV105608363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily