Provider Demographics
NPI:1144222662
Name:PENNINGTON, MELLISSA DIANNE (CRNA)
Entity Type:Individual
Prefix:
First Name:MELLISSA
Middle Name:DIANNE
Last Name:PENNINGTON
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 1:4 OCEAN VIEW DR
Mailing Address - Street 2:
Mailing Address - City:GULF BREEZE
Mailing Address - State:FL
Mailing Address - Zip Code:32561-2436
Mailing Address - Country:US
Mailing Address - Phone:850-934-8157
Mailing Address - Fax:
Practice Address - Street 1:4 OCEAN VIEW DR
Practice Address - Street 2:
Practice Address - City:GULF BREEZE
Practice Address - State:FL
Practice Address - Zip Code:32561-2436
Practice Address - Country:US
Practice Address - Phone:850-934-8157
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP9212211367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLG3473OtherBLUE CROSS & BLUE SHIELD
AL59170994OtherBLUE CROSS & BLUE SHIELD
FLG3473ZMedicare ID - Type Unspecified