Provider Demographics
NPI:1063118123
Name:WILSON- PRIMUS, MELITA CLARESA (PMHNP-BC)
Entity type:Individual
Prefix:
First Name:MELITA
Middle Name:CLARESA
Last Name:WILSON- PRIMUS
Suffix:
Gender:F
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:350 POPLAR DR
Mailing Address - Street 2:
Mailing Address - City:PETERSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:23805-9367
Mailing Address - Country:US
Mailing Address - Phone:866-546-2229
Mailing Address - Fax:
Practice Address - Street 1:508 S INDEPENDENCE BLVD # 200202
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23452-1178
Practice Address - Country:US
Practice Address - Phone:757-490-6463
Practice Address - Fax:757-930-6464
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-31
Last Update Date:2024-07-24
Deactivation Date:2024-05-13
Deactivation Code:
Reactivation Date:2024-06-05
Provider Licenses
StateLicense IDTaxonomies
VA0024186275363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty