Provider Demographics
NPI:1639231566
Name:STEPHENSON, MELISSA (CRNA)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:
Last Name:STEPHENSON
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:PO BOX 11225
Mailing Address - Street 2:
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37401-2225
Mailing Address - Country:US
Mailing Address - Phone:423-892-5602
Mailing Address - Fax:423-892-5838
Practice Address - Street 1:975 E. THIRD ST
Practice Address - Street 2:
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37403-2147
Practice Address - Country:US
Practice Address - Phone:423-778-7608
Practice Address - Fax:423-778-2360
Is Sole Proprietor?:No
Enumeration Date:2006-12-15
Last Update Date:2010-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNRN111442163W00000X
TNAPN11749367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAN451247OtherWELLCARE (GA MEDICAID)
TNP00264965OtherRAILROAD MEDICARE
TN3635803Medicaid
GA445713084AMedicaid
AL009933493Medicaid
TN4115498OtherBLUE CROSS BLUE SHIELD TN
TN3635803Medicare PIN