Provider Demographics
NPI:1003585100
Name:JOHNSON, MELANIE MEGAN (LVN)
Entity Type:Individual
Prefix:MS
First Name:MELANIE
Middle Name:MEGAN
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:LVN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1066 PLUMAS AVE
Mailing Address - Street 2:
Mailing Address - City:OROVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95965-3231
Mailing Address - Country:US
Mailing Address - Phone:530-403-6837
Mailing Address - Fax:
Practice Address - Street 1:1066 PLUMAS AVE
Practice Address - Street 2:
Practice Address - City:OROVILLE
Practice Address - State:CA
Practice Address - Zip Code:95965-3231
Practice Address - Country:US
Practice Address - Phone:530-403-6837
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-10
Last Update Date:2021-10-19
Deactivation Date:2021-09-13
Deactivation Code:
Reactivation Date:2021-09-30
Provider Licenses
StateLicense IDTaxonomies
CA711429164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes164X00000XNursing Service ProvidersLicensed Vocational NurseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA711429Medicaid