Provider Demographics
NPI:1699051854
Name:WILSON, MELISSA MARIE (LMT)
Entity type:Individual
Prefix:MRS
First Name:MELISSA
Middle Name:MARIE
Last Name:WILSON
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:MISS
Other - First Name:MELISSA
Other - Middle Name:MARIE
Other - Last Name:MARCHI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMT
Mailing Address - Street 1:1011 N STATE ROAD 7
Mailing Address - Street 2:SUITE D
Mailing Address - City:ROYAL PALM BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33411-5184
Mailing Address - Country:US
Mailing Address - Phone:561-333-8353
Mailing Address - Fax:
Practice Address - Street 1:1011 N STATE ROAD 7
Practice Address - Street 2:SUITE D
Practice Address - City:ROYAL PALM BEACH
Practice Address - State:FL
Practice Address - Zip Code:33411-5184
Practice Address - Country:US
Practice Address - Phone:561-333-8353
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-01
Last Update Date:2011-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL63722171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor