Healthcare Provider Details

I. General information

NPI: 1700873528
Provider Name (Legal Business Name): MELISSA LOUISE WILSON FAMILY NURSE PRACTIT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/06/2005
Last Update Date: 06/16/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

524 SPRUCE STREET UNIT 3
BROOKINGS OR
97415
US

IV. Provider business mailing address

15438 SOUTHWIND LANE
BROOKINGS OR
97415
US

V. Phone/Fax

Practice location:
  • Phone: 541-412-3726
  • Fax: 541-412-3729
Mailing address:
  • Phone: 541-412-3726
  • Fax: 541-412-3729

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberN32717
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code367A00000X
TaxonomyAdvanced Practice Midwife
License NumberN32717
License Number StateID
# 3
Primary TaxonomyN
Taxonomy Code367A00000X
TaxonomyAdvanced Practice Midwife
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number201350121NP
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: