Provider Demographics
NPI:1861691933
Name:WILSON, MELISSA SUE (PT)
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:SUE
Last Name:WILSON
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:53408 50TH ST
Mailing Address - Street 2:
Mailing Address - City:MILES
Mailing Address - State:IA
Mailing Address - Zip Code:52064-9532
Mailing Address - Country:US
Mailing Address - Phone:563-682-7409
Mailing Address - Fax:
Practice Address - Street 1:105 1ST AVE NW
Practice Address - Street 2:
Practice Address - City:PRESTON
Practice Address - State:IA
Practice Address - Zip Code:52069-9512
Practice Address - Country:US
Practice Address - Phone:563-343-0183
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-17
Last Update Date:2020-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA03240208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA31600OtherBLUE CROSS OF IOWA