Provider Demographics
NPI:1568191419
Name:JOHNSON, MELENIE ETHEL (LVN)
Entity Type:Individual
Prefix:MRS
First Name:MELENIE
Middle Name:ETHEL
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:LVN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:29375 ARIEL ST
Mailing Address - Street 2:
Mailing Address - City:MURRIETA
Mailing Address - State:CA
Mailing Address - Zip Code:92563-2737
Mailing Address - Country:US
Mailing Address - Phone:951-795-0250
Mailing Address - Fax:
Practice Address - Street 1:28999 OLD TOWN FRONT ST STE 102104
Practice Address - Street 2:
Practice Address - City:TEMECULA
Practice Address - State:CA
Practice Address - Zip Code:92590-5805
Practice Address - Country:US
Practice Address - Phone:951-261-8392
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-07
Last Update Date:2023-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA719197164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse