Provider Demographics
NPI:1255728564
Name:WILSON, MELISSA
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 753
Mailing Address - Street 2:
Mailing Address - City:ANTLERS
Mailing Address - State:OK
Mailing Address - Zip Code:74523-0753
Mailing Address - Country:US
Mailing Address - Phone:580-209-2235
Mailing Address - Fax:
Practice Address - Street 1:19437 N 4230 RD
Practice Address - Street 2:
Practice Address - City:ANTLERS
Practice Address - State:OK
Practice Address - Zip Code:74523-0753
Practice Address - Country:US
Practice Address - Phone:580-209-2235
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-24
Last Update Date:2015-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKR112330163WA2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WA2000XNursing Service ProvidersRegistered NurseAdministrator