Healthcare Provider Details

I. General information

NPI: 1508731480
Provider Name (Legal Business Name): MELISSA HERSOM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/09/2025
Last Update Date: 10/09/2025
Certification Date: 10/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

522 BATH RD
WISCASSET ME
04578-4640
US

IV. Provider business mailing address

88 MIDDLE RD
EDGECOMB ME
04556-3124
US

V. Phone/Fax

Practice location:
  • Phone: 207-315-8605
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WA2000X
TaxonomyAdministrator Registered Nurse
License NumberRN79489
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: