Provider Demographics
NPI:1538206545
Name:PERKINS-FAIRBANKS, MELANIE MARIE (NP-C, PMHNP-BC)
Entity type:Individual
Prefix:MS
First Name:MELANIE
Middle Name:MARIE
Last Name:PERKINS-FAIRBANKS
Suffix:
Gender:F
Credentials:NP-C, PMHNP-BC
Other - Prefix:
Other - First Name:MELANIE
Other - Middle Name:MARIE
Other - Last Name:PERKINS-GRAHAM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP-C, PMHNP-BC
Mailing Address - Street 1:111 S BROAD ST STE 209
Mailing Address - Street 2:
Mailing Address - City:LANCASTER
Mailing Address - State:OH
Mailing Address - Zip Code:43130-4383
Mailing Address - Country:US
Mailing Address - Phone:614-301-6479
Mailing Address - Fax:740-277-7433
Practice Address - Street 1:111 S BROAD ST STE 209
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:OH
Practice Address - Zip Code:43130
Practice Address - Country:US
Practice Address - Phone:614-301-6479
Practice Address - Fax:740-277-7433
Is Sole Proprietor?:No
Enumeration Date:2007-01-31
Last Update Date:2018-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAPRN.CNP.07832363LF0000X
OHNP07832363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2797479Medicaid
OHPENP23651Medicare PIN