Provider Demographics
NPI:1215535257
Name:JOHNSTON, MELISSA LEE (PA)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:LEE
Last Name:JOHNSTON
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:MELISSA
Other - Middle Name:
Other - Last Name:AMOS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 635283
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45263-5283
Mailing Address - Country:US
Mailing Address - Phone:859-212-7000
Mailing Address - Fax:859-212-7010
Practice Address - Street 1:2626 ALEXANDRIA PIKE
Practice Address - Street 2:
Practice Address - City:HIGHLAND HEIGHTS
Practice Address - State:KY
Practice Address - Zip Code:41076-1530
Practice Address - Country:US
Practice Address - Phone:859-212-7000
Practice Address - Fax:859-212-7010
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-12
Last Update Date:2024-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50.006695RX363A00000X
KYPA2761363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty