Provider Demographics
NPI:1568815793
Name:JOHNSON, MELISSA APRIL ROSE
Entity Type:Individual
Prefix:MRS
First Name:MELISSA
Middle Name:APRIL ROSE
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 1:301 MEDICAL AVE
Mailing Address - Street 2:SUITE A
Mailing Address - City:ANDALUSIA
Mailing Address - State:AL
Mailing Address - Zip Code:36420-1102
Mailing Address - Country:US
Mailing Address - Phone:334-222-1366
Mailing Address - Fax:
Practice Address - Street 1:301 MEDICAL AVE
Practice Address - Street 2:SUITE A
Practice Address - City:ANDALUSIA
Practice Address - State:AL
Practice Address - Zip Code:36420
Practice Address - Country:US
Practice Address - Phone:334-222-1366
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-07-22
Last Update Date:2018-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-097267363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner