Healthcare Provider Details

I. General information

NPI: 1336185206
Provider Name (Legal Business Name): MELODY C SECREST CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 06/21/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

242A 9TH AVENUE DR NE
HICKORY NC
28601-3828
US

IV. Provider business mailing address

PO BOX 2429
MURRELLS INLET SC
29576-2429
US

V. Phone/Fax

Practice location:
  • Phone: 828-327-6673
  • Fax:
Mailing address:
  • Phone: 843-651-2624
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number049095
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: