Provider Demographics
NPI:1356629968
Name:JOHNSTON, MELANIE JEANNINE (COTA/L)
Entity Type:Individual
Prefix:MRS
First Name:MELANIE
Middle Name:JEANNINE
Last Name:JOHNSTON
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:248 GENEVA BLVD
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:MS
Mailing Address - Zip Code:39110-7739
Mailing Address - Country:US
Mailing Address - Phone:601-260-7793
Mailing Address - Fax:
Practice Address - Street 1:248 GENEVA BLVD
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:MS
Practice Address - Zip Code:39110-7739
Practice Address - Country:US
Practice Address - Phone:601-260-7793
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-31
Last Update Date:2011-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSTA1800314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility