Healthcare Provider Details

I. General information

NPI: 1144831165
Provider Name (Legal Business Name): MELISSA BLACKMAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/13/2020
Last Update Date: 08/13/2020
Certification Date: 08/13/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5923 WADESVILLE RD
BELLEVILLE WV
26133-8368
US

IV. Provider business mailing address

5923 WADESVILLE RD
BELLEVILLE WV
26133-8368
US

V. Phone/Fax

Practice location:
  • Phone: 304-494-3969
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3747P1801X
TaxonomyPersonal Care Attendant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: