Provider Demographics
NPI:1265941694
Name:WILSON, MELISSA JANE (NP)
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:JANE
Last Name:WILSON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:MELISSA
Other - Middle Name:JANE
Other - Last Name:HULL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:110 EXECUTIVE PARK DR
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:TN
Mailing Address - Zip Code:37716-6876
Mailing Address - Country:US
Mailing Address - Phone:865-494-9241
Mailing Address - Fax:865-374-2121
Practice Address - Street 1:110 EXECUTIVE PARK DR
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:TN
Practice Address - Zip Code:37716-6876
Practice Address - Country:US
Practice Address - Phone:865-494-9241
Practice Address - Fax:865-374-2121
Is Sole Proprietor?:No
Enumeration Date:2017-09-28
Last Update Date:2021-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3012980363L00000X
TN23186363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ044813Medicaid