Provider Demographics
NPI:1821397506
Name:JOHNSON, MELODY MARQURIS (LPN)
Entity Type:Individual
Prefix:MRS
First Name:MELODY
Middle Name:MARQURIS
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2911 N 12TH ST
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53206-2618
Mailing Address - Country:US
Mailing Address - Phone:414-736-1121
Mailing Address - Fax:
Practice Address - Street 1:2911 N 12TH ST
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53206-2618
Practice Address - Country:US
Practice Address - Phone:414-736-1121
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-21
Last Update Date:2011-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI306870-031164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse