Provider Demographics
NPI:1831840677
Name:WILBURN, MELISSA (PTA)
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:
Last Name:WILBURN
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:210 COSBY CIR
Mailing Address - Street 2:
Mailing Address - City:TAZEWELL
Mailing Address - State:TN
Mailing Address - Zip Code:37879-3917
Mailing Address - Country:US
Mailing Address - Phone:606-269-8661
Mailing Address - Fax:
Practice Address - Street 1:110 SKYLINE DR STE B
Practice Address - Street 2:
Practice Address - City:MAYNARDVILLE
Practice Address - State:TN
Practice Address - Zip Code:37807-3063
Practice Address - Country:US
Practice Address - Phone:865-992-6933
Practice Address - Fax:865-992-6870
Is Sole Proprietor?:No
Enumeration Date:2022-01-13
Last Update Date:2022-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN3082225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant