Provider Demographics
NPI:1427217595
Name:BLACKER, MELANIE JANE
Entity Type:Individual
Prefix:
First Name:MELANIE
Middle Name:JANE
Last Name:BLACKER
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 1:155 MEMORIAL DR
Mailing Address - Street 2:PO BOX 3000
Mailing Address - City:PINEHURST
Mailing Address - State:NC
Mailing Address - Zip Code:28374-8710
Mailing Address - Country:US
Mailing Address - Phone:910-715-2164
Mailing Address - Fax:
Practice Address - Street 1:155 MEMORIAL DR
Practice Address - Street 2:
Practice Address - City:PINEHURST
Practice Address - State:NC
Practice Address - Zip Code:28374-8710
Practice Address - Country:US
Practice Address - Phone:910-715-2164
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-04
Last Update Date:2015-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NC2011-004692084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program