Provider Demographics
NPI:1316219397
Name:CAUSTRITA, MELANIE ANN (ACNP-BC)
Entity type:Individual
Prefix:
First Name:MELANIE
Middle Name:ANN
Last Name:CAUSTRITA
Suffix:
Gender:
Credentials:ACNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11109 PARKVIEW PLAZA DR # 117
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46845-1701
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:433 W HIGH ST
Practice Address - Street 2:
Practice Address - City:BRYAN
Practice Address - State:OH
Practice Address - Zip Code:43506-1690
Practice Address - Country:US
Practice Address - Phone:419-630-2028
Practice Address - Fax:419-630-2029
Is Sole Proprietor?:No
Enumeration Date:2012-02-06
Last Update Date:2025-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC18736363L00000X
OHAPRN.CNP.13124363L00000X
OHCOA.13124- NP363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0065971Medicaid
OHH091786Medicare PIN