Provider Demographics
NPI:1083170591
Name:BLACKBURN, MELISSA ANNE
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:ANNE
Last Name:BLACKBURN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2408 NW 106TH ST
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98685-4871
Mailing Address - Country:US
Mailing Address - Phone:971-218-6542
Mailing Address - Fax:
Practice Address - Street 1:9300 NE OAK VIEW DR
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98662-6157
Practice Address - Country:US
Practice Address - Phone:360-675-2211
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-20
Last Update Date:2019-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator