Provider Demographics
NPI:1457505984
Name:BLANKENSHIP, MELISSA FAWN (CRNA)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:FAWN
Last Name:BLANKENSHIP
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:MELISSA
Other - Middle Name:FAWN
Other - Last Name:STAATS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 449
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:OH
Mailing Address - Zip Code:45750-0449
Mailing Address - Country:US
Mailing Address - Phone:740-374-4500
Mailing Address - Fax:740-374-5887
Practice Address - Street 1:100 JACKSON PIKE
Practice Address - Street 2:
Practice Address - City:GALLIPOLIS
Practice Address - State:OH
Practice Address - Zip Code:45631-1560
Practice Address - Country:US
Practice Address - Phone:855-446-5937
Practice Address - Fax:740-376-1940
Is Sole Proprietor?:Yes
Enumeration Date:2008-11-11
Last Update Date:2019-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRN.339875163W00000X
OHAPRN.CRNA.10400367500000X
WVAPRN46602367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2890760Medicaid
WV3810013880Medicaid
OH000000593388OtherANTHEM
OH000000642757OtherANTHEM
WV3810013880Medicaid
OH8243881Medicare PIN