Basic Information
| Provider Information | |||||||||
| NPI: | 1215901459 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WILGUS | ||||||||
| FirstName: | MELISSA | ||||||||
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| Credential: | MS, ATC, CSCS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4162 BERRYFIELD DR | ||||||||
| Address2: | |||||||||
| City: | GAHANNA | ||||||||
| State: | OH | ||||||||
| PostalCode: | 432305102 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6144288303 | ||||||||
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| Practice Location | |||||||||
| Address1: | 479 PARSONS AVE | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 432155577 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6147225577 | ||||||||
| FaxNumber: | 6147225581 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/15/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2255A2300X | AT 1026 | OH | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Specialist/Technologist | Athletic Trainer |
No ID Information.