Provider Demographics
NPI:1457000697
Name:JOHNSON, MELISSA LANNIE
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:LANNIE
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:PO BOX 774
Mailing Address - Street 2:
Mailing Address - City:PULLMAN
Mailing Address - State:WA
Mailing Address - Zip Code:99163-0774
Mailing Address - Country:US
Mailing Address - Phone:425-508-8717
Mailing Address - Fax:
Practice Address - Street 1:1035 NW NYE ST STE A
Practice Address - Street 2:
Practice Address - City:PULLMAN
Practice Address - State:WA
Practice Address - Zip Code:99163-3428
Practice Address - Country:US
Practice Address - Phone:425-508-8717
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-23
Last Update Date:2022-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WASC604885731041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical