Provider Demographics
NPI:1396007373
Name:BLACK, MELANIE (CRNA)
Entity Type:Individual
Prefix:
First Name:MELANIE
Middle Name:
Last Name:BLACK
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 1:1106 SAN AUGUSTINE DR
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78733-2562
Mailing Address - Country:US
Mailing Address - Phone:828-423-4354
Mailing Address - Fax:
Practice Address - Street 1:1004 S ROCK ST
Practice Address - Street 2:
Practice Address - City:GEORGETOWN
Practice Address - State:TX
Practice Address - Zip Code:78626-5837
Practice Address - Country:US
Practice Address - Phone:512-374-1876
Practice Address - Fax:512-371-8788
Is Sole Proprietor?:No
Enumeration Date:2012-06-14
Last Update Date:2012-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX705859367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered