Provider Demographics
NPI:1093983504
Name:MELTON, LAURA BLACKWELL (CRNA)
Entity Type:Individual
Prefix:MRS
First Name:LAURA
Middle Name:BLACKWELL
Last Name:MELTON
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 277723
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30384-7723
Mailing Address - Country:US
Mailing Address - Phone:864-560-4123
Mailing Address - Fax:
Practice Address - Street 1:101 E WOOD ST
Practice Address - Street 2:
Practice Address - City:SPARTANBURG
Practice Address - State:SC
Practice Address - Zip Code:29303-3040
Practice Address - Country:US
Practice Address - Phone:864-560-6122
Practice Address - Fax:864-560-6276
Is Sole Proprietor?:No
Enumeration Date:2008-02-19
Last Update Date:2010-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC95563163W00000X
SC3577367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCP00691781OtherRR MEDICARE
SCAN1719Medicaid
SCQ34820Medicare UPIN
SCQ348203365Medicare PIN