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General NPI Number Information
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NPI Number | 1427815059
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Entity Type | Individual
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Provider Name | BLAKE MYLES MERANTO DNP, FNP
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Gender | Male
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Dates
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Enumeration Date | 02/29/2024
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Last Update Date | 02/29/2024
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Provider Practice Location Address
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Address Line | 1706 W 10TH ST
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City | LAUREL
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State | MS
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Zip | 39440-2557
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Country | US
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Telephone | 601-682-0455
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Fax | 601-682-0456
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Provider Business Mailing Address
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Address Line | 303 N 20TH AVE
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City | HATTIESBURG
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State | MS
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Zip | 39401-4750
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Country | US
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Telephone | 228-493-2562
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number | 906558
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License Number State | MS
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