Provider Demographics
NPI:1982295820
Name:VICKERY, MELISSA G (CRNA)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:G
Last Name:VICKERY
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 1:237 OLD TIMEY TRL
Mailing Address - Street 2:
Mailing Address - City:MOULTRIE
Mailing Address - State:GA
Mailing Address - Zip Code:31788-7093
Mailing Address - Country:US
Mailing Address - Phone:229-873-1804
Mailing Address - Fax:
Practice Address - Street 1:230 HOSPITAL PLZ
Practice Address - Street 2:
Practice Address - City:WESTON
Practice Address - State:WV
Practice Address - Zip Code:26452-8558
Practice Address - Country:US
Practice Address - Phone:304-269-8000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-02
Last Update Date:2021-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV108463367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Single Specialty