Provider Demographics
NPI:1609844117
Name:LEFAVE, MELISSA CAROL (CRNA)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:CAROL
Last Name:LEFAVE
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 1:130 WOODLAND DR
Mailing Address - Street 2:
Mailing Address - City:BROWNSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:38012-6875
Mailing Address - Country:US
Mailing Address - Phone:731-779-1724
Mailing Address - Fax:731-779-1724
Practice Address - Street 1:401 E TICKLE ST
Practice Address - Street 2:
Practice Address - City:DYERSBURG
Practice Address - State:TN
Practice Address - Zip Code:38024-3119
Practice Address - Country:US
Practice Address - Phone:731-285-1545
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-09
Last Update Date:2011-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN055149367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN36319731Medicare PIN