Provider Demographics
NPI:1447651419
Name:WILD, MELISSA (NP)
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:
Last Name:WILD
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7557B DANNAHER DR STE 225
Mailing Address - Street 2:
Mailing Address - City:POWELL
Mailing Address - State:TN
Mailing Address - Zip Code:37849-3568
Mailing Address - Country:US
Mailing Address - Phone:865-647-5800
Mailing Address - Fax:865-647-5979
Practice Address - Street 1:7557B DANNAHER DR STE 225
Practice Address - Street 2:
Practice Address - City:POWELL
Practice Address - State:TN
Practice Address - Zip Code:37849-3568
Practice Address - Country:US
Practice Address - Phone:865-647-5800
Practice Address - Fax:865-647-5979
Is Sole Proprietor?:No
Enumeration Date:2014-09-10
Last Update Date:2019-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN19166363LF0000X
TNAPN19166363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily