Provider Demographics
NPI:1003181926
Name:JOHNSON, MELLYN AILEEN (APRN)
Entity Type:Individual
Prefix:
First Name:MELLYN
Middle Name:AILEEN
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:MELLYN
Other - Middle Name:AILEEN
Other - Last Name:BUTLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:850 HARVARD WAY
Mailing Address - Street 2:
Mailing Address - City:RENO
Mailing Address - State:NV
Mailing Address - Zip Code:89502-2055
Mailing Address - Country:US
Mailing Address - Phone:775-982-5262
Mailing Address - Fax:775-982-5496
Practice Address - Street 1:1500 E 2ND ST
Practice Address - Street 2:STE 100
Practice Address - City:RENO
Practice Address - State:NV
Practice Address - Zip Code:89502-1262
Practice Address - Country:US
Practice Address - Phone:775-982-5003
Practice Address - Fax:775-982-5103
Is Sole Proprietor?:No
Enumeration Date:2012-03-09
Last Update Date:2019-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVAPRN001367363L00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1003181926Medicaid
12368895OtherCAQH
NVGJ020ZMedicare PIN