Healthcare Provider Details

I. General information

NPI: 1376162784
Provider Name (Legal Business Name): MELYSSA DIANE WILDE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/15/2020
Last Update Date: 04/09/2025
Certification Date: 04/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

609 W GERMANTOWN PIKE STE 220
EAST NORRITON PA
19403-4261
US

IV. Provider business mailing address

609 W GERMANTOWN PIKE STE 220
EAST NORRITON PA
19403-4261
US

V. Phone/Fax

Practice location:
  • Phone: 484-622-7940
  • Fax:
Mailing address:
  • Phone: 484-622-7940
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License NumberTL.0008180
License Number StateCO
# 2
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License NumberMD484622
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: