Provider Demographics
NPI:1396069126
Name:BLACHLY, MELISA JO (FNP-C)
Entity type:Individual
Prefix:
First Name:MELISA
Middle Name:JO
Last Name:BLACHLY
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301 PALMETTO PARK BLVD
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:SC
Mailing Address - Zip Code:29072-7872
Mailing Address - Country:US
Mailing Address - Phone:803-996-1500
Mailing Address - Fax:803-996-1510
Practice Address - Street 1:5425 W SUNSET RD
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85743-9237
Practice Address - Country:US
Practice Address - Phone:520-907-7765
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-03-23
Last Update Date:2022-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ146735163W00000X
AZ221053363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC322842Medicaid
SC322842Medicaid