Provider Demographics
NPI:1548870892
Name:WILSON, MELISSA MICHELLE (FNP)
Entity type:Individual
Prefix:MRS
First Name:MELISSA
Middle Name:MICHELLE
Last Name:WILSON
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:MISS
Other - First Name:MELISSA
Other - Middle Name:MICHELLE
Other - Last Name:KIRKLAND
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:PO BOX 846098
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-6098
Mailing Address - Country:US
Mailing Address - Phone:903-606-6400
Mailing Address - Fax:903-606-1522
Practice Address - Street 1:2604 SAINT MICHAEL DR STE 237
Practice Address - Street 2:
Practice Address - City:TEXARKANA
Practice Address - State:TX
Practice Address - Zip Code:75503-2378
Practice Address - Country:US
Practice Address - Phone:903-614-5180
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-02
Last Update Date:2023-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP142897363L00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200969990AMedicaid