Provider Demographics
NPI:1700873528
Name:WILSON, MELISSA LOUISE (FAMILY NURSE PRACTIT)
Entity Type:Individual
Prefix:MS
First Name:MELISSA
Middle Name:LOUISE
Last Name:WILSON
Suffix:
Gender:F
Credentials:FAMILY NURSE PRACTIT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15438 SOUTHWIND LANE
Mailing Address - Street 2:
Mailing Address - City:BROOKINGS
Mailing Address - State:OR
Mailing Address - Zip Code:97415
Mailing Address - Country:US
Mailing Address - Phone:541-412-3726
Mailing Address - Fax:541-412-3729
Practice Address - Street 1:524 SPRUCE STREET UNIT 3
Practice Address - Street 2:
Practice Address - City:BROOKINGS
Practice Address - State:OR
Practice Address - Zip Code:97415
Practice Address - Country:US
Practice Address - Phone:541-412-3726
Practice Address - Fax:541-412-3729
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-06
Last Update Date:2016-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDN32717363LF0000X, 367A00000X
367A00000X
OR201350121NP363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID806760300Medicaid
WA9639428Medicaid
ID806760300Medicaid