Provider Demographics
NPI:1043547524
Name:BLACKWOOD, MELISSA CAROL (CRNA)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:CAROL
Last Name:BLACKWOOD
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3181
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46206-3181
Mailing Address - Country:US
Mailing Address - Phone:317-614-9863
Mailing Address - Fax:844-876-0873
Practice Address - Street 1:907 E LAMAR ALEXANDER PKWY
Practice Address - Street 2:
Practice Address - City:MARYVILLE
Practice Address - State:TN
Practice Address - Zip Code:37804-5015
Practice Address - Country:US
Practice Address - Phone:865-983-7211
Practice Address - Fax:865-983-8043
Is Sole Proprietor?:No
Enumeration Date:2009-11-04
Last Update Date:2019-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNAPN14537367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN4246033OtherBLUE CROSS BLUE SHIELD TN
TN1516508Medicaid
TN103I438453Medicare PIN