Provider Demographics
NPI:1326519828
Name:JOHNSON, MELISSA
Entity Type:Individual
Prefix:
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 1:4153 HEADLAND CT
Mailing Address - Street 2:
Mailing Address - City:MASON
Mailing Address - State:OH
Mailing Address - Zip Code:45040-7683
Mailing Address - Country:US
Mailing Address - Phone:513-229-0011
Mailing Address - Fax:
Practice Address - Street 1:4361 IRWIN SIMPSON RD
Practice Address - Street 2:
Practice Address - City:MASON
Practice Address - State:OH
Practice Address - Zip Code:45040-9479
Practice Address - Country:US
Practice Address - Phone:513-336-3543
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-09
Last Update Date:2018-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH023512363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH023512OtherAPRN CNP