Provider Demographics
NPI:1356383327
Name:WILSON, MELISSA M (PHYSICAL THERAPIST)
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:M
Last Name:WILSON
Suffix:
Gender:F
Credentials:PHYSICAL THERAPIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10212 NE 144TH ST
Mailing Address - Street 2:
Mailing Address - City:JONES
Mailing Address - State:OK
Mailing Address - Zip Code:73049-0089
Mailing Address - Country:US
Mailing Address - Phone:405-819-8014
Mailing Address - Fax:
Practice Address - Street 1:22087 BLACK WALNUT CIR
Practice Address - Street 2:
Practice Address - City:EDMOND
Practice Address - State:OK
Practice Address - Zip Code:73012-4228
Practice Address - Country:US
Practice Address - Phone:405-880-5120
Practice Address - Fax:405-212-5093
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-12
Last Update Date:2023-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK3798225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist