Provider Demographics
NPI:1174152912
Name:WILSON, MELISSA MARIE (RN, IBCLC)
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:MARIE
Last Name:WILSON
Suffix:
Gender:F
Credentials:RN, IBCLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:905 FORKSBRIDGE CT
Mailing Address - Street 2:
Mailing Address - City:GAMBRILLS
Mailing Address - State:MD
Mailing Address - Zip Code:21054-1655
Mailing Address - Country:US
Mailing Address - Phone:301-266-0475
Mailing Address - Fax:
Practice Address - Street 1:905 FORKSBRIDGE CT
Practice Address - Street 2:
Practice Address - City:GAMBRILLS
Practice Address - State:MD
Practice Address - Zip Code:21054-1655
Practice Address - Country:US
Practice Address - Phone:301-266-0475
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-03
Last Update Date:2020-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR148396163WL0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WL0100XNursing Service ProvidersRegistered NurseLactation Consultant