Provider Demographics
NPI:1144632225
Name:MELLOTT, EMILY RENEE (CRNA)
Entity type:Individual
Prefix:
First Name:EMILY
Middle Name:RENEE
Last Name:MELLOTT
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:EMILY
Other - Middle Name:
Other - Last Name:DECKER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:785 5TH AVE STE 3
Mailing Address - Street 2:
Mailing Address - City:CHAMBERSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17201-4232
Mailing Address - Country:US
Mailing Address - Phone:717-263-9555
Mailing Address - Fax:717-709-6529
Practice Address - Street 1:112 N 7TH ST
Practice Address - Street 2:
Practice Address - City:CHAMBERSBURG
Practice Address - State:PA
Practice Address - Zip Code:17201-1720
Practice Address - Country:US
Practice Address - Phone:717-267-7164
Practice Address - Fax:717-267-7414
Is Sole Proprietor?:No
Enumeration Date:2014-05-23
Last Update Date:2022-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA100185367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
12704911OtherCAQH
PA102960340Medicaid