Healthcare Provider Details

I. General information

NPI: 1770815755
Provider Name (Legal Business Name): MELISSA D WILKES
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/02/2010
Last Update Date: 07/02/2025
Certification Date: 07/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13838 TILDEN RD
WINTER GARDEN FL
34787-5318
US

IV. Provider business mailing address

25 W CRYSTAL LAKE ST STE 200
ORLANDO FL
32806-4476
US

V. Phone/Fax

Practice location:
  • Phone: 407-287-9113
  • Fax:
Mailing address:
  • Phone: 407-254-2500
  • Fax: 407-423-2789

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberAMD-1144
License Number StateHI
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA9119844
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: