Basic Information
Provider Information | |||||||||
NPI: | 1073883468 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | WILSON | ||||||||
FirstName: | MELISSA | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | LPN, OTC, CPED, BOCO | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1701 WESTCHESTER DRIVE | ||||||||
Address2: | SUITE 850 | ||||||||
City: | HIGH POINT | ||||||||
State: | NC | ||||||||
PostalCode: | 272627254 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3368022536 | ||||||||
FaxNumber: | 3368022534 | ||||||||
Practice Location | |||||||||
Address1: | 611 N LINDSAY ST | ||||||||
Address2: | SUITE 200 | ||||||||
City: | HIGH POINT | ||||||||
State: | NC | ||||||||
PostalCode: | 272624300 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3368022250 | ||||||||
FaxNumber: | 3368022251 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/03/2012 | ||||||||
LastUpdateDate: | 03/12/2015 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 164W00000X | 034220 | NC | N |   | Nursing Service Providers | Licensed Practical Nurse |   | 222Z00000X | BOCO C50277 |   | Y |   | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Orthotist |   | 224L00000X | ABC CPED 0855 |   | N |   | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Pedorthist |   |
ID Information
ID | Type | State | Issuer | Description | 7795543 | 05 | NC |   | MEDICAID |