Provider Demographics
NPI:1144768748
Name:JOHNSON, MELISSA
Entity Type:Individual
Prefix:MRS
First Name:MELISSA
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9717 W KUSE RD
Mailing Address - Street 2:
Mailing Address - City:FRANKFORT
Mailing Address - State:IL
Mailing Address - Zip Code:60423
Mailing Address - Country:US
Mailing Address - Phone:708-268-2877
Mailing Address - Fax:
Practice Address - Street 1:9717 W KUSE RD
Practice Address - Street 2:
Practice Address - City:FRANKFORT
Practice Address - State:IL
Practice Address - Zip Code:60423-8003
Practice Address - Country:US
Practice Address - Phone:708-268-2877
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-03
Last Update Date:2017-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILJ52555093663390200000X, 2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer