Healthcare Provider Details

I. General information

NPI: 1588646889
Provider Name (Legal Business Name): MICHAEL MELLON CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/14/2005
Last Update Date: 07/30/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 HIGHLANDS DR
LITITZ PA
17543
US

IV. Provider business mailing address

409 S 2ND ST STE 2F
HARRISBURG PA
17104-1612
US

V. Phone/Fax

Practice location:
  • Phone: 717-782-3282
  • Fax: 717-231-8964
Mailing address:
  • Phone: 717-782-3282
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberRN261026L
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: