Healthcare Provider Details

I. General information

NPI: 1316219397
Provider Name (Legal Business Name): MELANIE ANN CAUSTRITA ACNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/06/2012
Last Update Date: 05/02/2025
Certification Date: 05/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

433 W HIGH ST
BRYAN OH
43506-1690
US

IV. Provider business mailing address

11109 PARKVIEW PLAZA DR # 117
FORT WAYNE IN
46845-1701
US

V. Phone/Fax

Practice location:
  • Phone: 419-630-2028
  • Fax: 419-630-2029
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number18736
License Number StateSC
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberAPRN.CNP.13124
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: