Provider Demographics
NPI:1174641963
Name:EDGE, MELYDIA J (CRNA)
Entity Type:Individual
Prefix:
First Name:MELYDIA
Middle Name:J
Last Name:EDGE
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:2430 EMERALD PL
Mailing Address - Street 2:SUITE 201
Mailing Address - City:GREENVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27834-5784
Mailing Address - Country:US
Mailing Address - Phone:252-752-2140
Mailing Address - Fax:252-752-3949
Practice Address - Street 1:2430 EMERALD PL
Practice Address - Street 2:SUITE 201
Practice Address - City:GREENVILLE
Practice Address - State:NC
Practice Address - Zip Code:27834-5784
Practice Address - Country:US
Practice Address - Phone:252-752-2140
Practice Address - Fax:252-752-3949
Is Sole Proprietor?:No
Enumeration Date:2007-03-27
Last Update Date:2011-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC181790163W00000X
NC038647367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCP00601268OtherRAILROAD MEDICARE
NC1174641963OtherTRICARE
NC8052891Medicaid
NCP00601268OtherRAILROAD MEDICARE
NC2618614Medicare PIN