Provider Demographics
NPI:1245514132
Name:EASLEY, MERINDA HAIRSTON
Entity type:Individual
Prefix:
First Name:MERINDA
Middle Name:HAIRSTON
Last Name:EASLEY
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:PO BOX 3085
Mailing Address - Street 2:
Mailing Address - City:MARTINSVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:24115-3085
Mailing Address - Country:US
Mailing Address - Phone:276-632-8612
Mailing Address - Fax:276-632-8712
Practice Address - Street 1:755 LAUREL PARK AVE
Practice Address - Street 2:
Practice Address - City:MARTINSVILLE
Practice Address - State:VA
Practice Address - Zip Code:24112-0253
Practice Address - Country:US
Practice Address - Phone:276-632-8612
Practice Address - Fax:276-632-8712
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-10
Last Update Date:2011-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0163720136Medicaid