Provider Demographics
NPI:1962919738
Name:MELLISH, HEATHER MICHELLE (CRNA)
Entity type:Individual
Prefix:
First Name:HEATHER
Middle Name:MICHELLE
Last Name:MELLISH
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:HEATHER
Other - Middle Name:MICHELLE
Other - Last Name:RASMUSSEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CRNA
Mailing Address - Street 1:4630 HELENA ST NE
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33703-4358
Mailing Address - Country:US
Mailing Address - Phone:813-951-0600
Mailing Address - Fax:
Practice Address - Street 1:2020 59TH ST W
Practice Address - Street 2:
Practice Address - City:BRADENTON
Practice Address - State:FL
Practice Address - Zip Code:34209-4604
Practice Address - Country:US
Practice Address - Phone:941-792-6611
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-03
Last Update Date:2022-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9336794367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL023548600Medicaid