Provider Demographics
NPI:1477816668
Name:BLACKMON, MELISSA MICHELLE (NP-C)
Entity Type:Individual
Prefix:MRS
First Name:MELISSA
Middle Name:MICHELLE
Last Name:BLACKMON
Suffix:
Gender:F
Credentials:NP-C
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 6069
Mailing Address - Street 2:
Mailing Address - City:WEST COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29171-6069
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:222 E MEDICAL LN STE 100&200
Practice Address - Street 2:
Practice Address - City:WEST COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29169-4847
Practice Address - Country:US
Practice Address - Phone:803-935-8410
Practice Address - Fax:803-936-7816
Is Sole Proprietor?:No
Enumeration Date:2012-06-21
Last Update Date:2020-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC17870363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner