Basic Information
| Provider Information | |||||||||
| NPI: | 1053393066 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GARRISON | ||||||||
| FirstName: | MELISSA | ||||||||
| MiddleName: | SUE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | N.P. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | WIMMER | ||||||||
| OtherFirstName: | MELISSA | ||||||||
| OtherMiddleName: | SUE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 38135 MARKET SQ | ||||||||
| Address2: | |||||||||
| City: | ZEPHYRHILLS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 335427505 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3525670188 | ||||||||
| FaxNumber: | 8133555101 | ||||||||
| Practice Location | |||||||||
| Address1: | 7229 US HIGHWAY 301 S | ||||||||
| Address2: | |||||||||
| City: | RIVERVIEW | ||||||||
| State: | FL | ||||||||
| PostalCode: | 335784346 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8136778418 | ||||||||
| FaxNumber: | 8133555906 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/16/2005 | ||||||||
| LastUpdateDate: | 07/30/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 07/30/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 4704194300 | MI | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363LF0000X | 9270004 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | AZ946Z | 01 | FL | MEDICARE PTAN | OTHER | 4741645 10 | 05 | MI | MEDICAID | Y0JU7 | 01 | FL | BCBS | OTHER | 700G560080 | 01 | MI | BCBS GROUP-THREE RIVERS HEALTH | OTHER | JQ238 | 01 | FL | MEDICARE | OTHER |