Provider Demographics
NPI:1629004346
Name:JOHNSON, MELANIE L (FNP)
Entity Type:Individual
Prefix:
First Name:MELANIE
Middle Name:L
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:629 KENESAW AVE
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37919-6660
Mailing Address - Country:US
Mailing Address - Phone:865-250-3405
Mailing Address - Fax:
Practice Address - Street 1:7565 DANNAHER DR
Practice Address - Street 2:
Practice Address - City:POWELL
Practice Address - State:TN
Practice Address - Zip Code:37849-4029
Practice Address - Country:US
Practice Address - Phone:865-859-8000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-24
Last Update Date:2023-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN11601363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3641091Medicaid
TN3641091Medicare ID - Type UnspecifiedLEGACY PIN
TN3721611Medicare ID - Type UnspecifiedLEGACY GROUP
Q50103Medicare UPIN