Healthcare Provider Details

I. General information

NPI: 1457505984
Provider Name (Legal Business Name): MELISSA FAWN BLANKENSHIP CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: MELISSA FAWN STAATS

II. Dates (important events)

Enumeration Date: 11/11/2008
Last Update Date: 12/03/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 JACKSON PIKE
GALLIPOLIS OH
45631-1560
US

IV. Provider business mailing address

PO BOX 449
MARIETTA OH
45750-0449
US

V. Phone/Fax

Practice location:
  • Phone: 855-446-5937
  • Fax: 740-376-1940
Mailing address:
  • Phone: 740-374-4500
  • Fax: 740-374-5887

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN.339875
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberAPRN.CRNA.10400
License Number StateOH
# 3
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberAPRN46602
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: