=====================================================
General NPI Number Information
=====================================================
NPI Number | 1760043921
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MELISSA M WILSON PT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/27/2019
-----------------------------------------------------
Last Update Date | 12/01/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 610 E BRANNON RD STE 200
-----------------------------------------------------
City | NICHOLASVILLE
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 40356-6046
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 859-260-5555
-----------------------------------------------------
Fax | 859-260-5556
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 734839
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60673-4839
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 502-253-4900
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | 004373
-----------------------------------------------------
License Number State | KY
-----------------------------------------------------