Provider Demographics
NPI:1952931933
Name:BOURGEOIS, MELISSA M (FNP)
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:M
Last Name:BOURGEOIS
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 TWIN PONDS LN
Mailing Address - Street 2:
Mailing Address - City:MORGANTOWN
Mailing Address - State:WV
Mailing Address - Zip Code:26508-4878
Mailing Address - Country:US
Mailing Address - Phone:985-804-1770
Mailing Address - Fax:
Practice Address - Street 1:527 MEDICAL PARK DR STE 205
Practice Address - Street 2:
Practice Address - City:BRIDGEPORT
Practice Address - State:WV
Practice Address - Zip Code:26330-9009
Practice Address - Country:US
Practice Address - Phone:681-342-3730
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-18
Last Update Date:2022-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV88110163W00000X
WV105067363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse