Healthcare Provider Details

I. General information

NPI: 1306396361
Provider Name (Legal Business Name): MELISSA LAREE WILMARTH CNM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/13/2016
Last Update Date: 06/02/2022
Certification Date: 06/14/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 WILLOW PLZ SUITE 201
VISALIA CA
93291-6206
US

IV. Provider business mailing address

2817 REILLY ST
FORT BRAGG NC
28310-7394
US

V. Phone/Fax

Practice location:
  • Phone: 559-627-9284
  • Fax: 559-713-0965
Mailing address:
  • Phone: 910-907-8333
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number235813
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: