=====================================================
General NPI Number Information
=====================================================
NPI Number | 1831422518
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MELISSA L WILSON FNP-BC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/11/2009
-----------------------------------------------------
Last Update Date | 10/30/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 710 FRANKLIN ST STE 200
-----------------------------------------------------
City | MICHIGAN CITY
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46360-3564
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 219-872-6200
-----------------------------------------------------
Fax | 219-879-2915
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 710 FRANKLIN ST STE 200
-----------------------------------------------------
City | MICHIGAN CITY
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46360-3564
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 219-872-6200
-----------------------------------------------------
Fax | 219-879-2915
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | 71003029A
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------