Provider Demographics
NPI:1952817850
Name:JOHNSON, MELINDA CATHERINE
Entity Type:Individual
Prefix:MRS
First Name:MELINDA
Middle Name:CATHERINE
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 1:1106 MELVILLE AVE
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33805-3959
Mailing Address - Country:US
Mailing Address - Phone:863-255-9370
Mailing Address - Fax:863-255-9370
Practice Address - Street 1:2736 W 10TH ST
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33805-3982
Practice Address - Country:US
Practice Address - Phone:863-255-9370
Practice Address - Fax:863-255-9370
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-14
Last Update Date:2017-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD1600XAmbulatory Health Care FacilitiesClinic/CenterDevelopmental Disabilities