Provider Demographics
NPI:1427815059
Name:MERANTO, BLAKE MYLES (DNP, FNP)
Entity type:Individual
Prefix:DR
First Name:BLAKE
Middle Name:MYLES
Last Name:MERANTO
Suffix:
Gender:M
Credentials:DNP, FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:303 N 20TH AVE
Mailing Address - Street 2:
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39401-4750
Mailing Address - Country:US
Mailing Address - Phone:228-493-2562
Mailing Address - Fax:
Practice Address - Street 1:1706 W 10TH ST
Practice Address - Street 2:
Practice Address - City:LAUREL
Practice Address - State:MS
Practice Address - Zip Code:39440-2557
Practice Address - Country:US
Practice Address - Phone:601-682-0455
Practice Address - Fax:601-682-0456
Is Sole Proprietor?:No
Enumeration Date:2024-02-29
Last Update Date:2024-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS906558363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily