Provider Demographics
NPI:1184340374
Name:JOHNSON, MELISSA A (LMT, LAC)
Entity type:Individual
Prefix:MS
First Name:MELISSA
Middle Name:A
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:LMT, LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:565 MAIN ST APT 3
Mailing Address - Street 2:
Mailing Address - City:POUGHKEEPSIE
Mailing Address - State:NY
Mailing Address - Zip Code:12601-3880
Mailing Address - Country:US
Mailing Address - Phone:646-745-7401
Mailing Address - Fax:
Practice Address - Street 1:565 MAIN ST APT 3
Practice Address - Street 2:
Practice Address - City:POUGHKEEPSIE
Practice Address - State:NY
Practice Address - Zip Code:12601-3880
Practice Address - Country:US
Practice Address - Phone:646-745-7401
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-18
Last Update Date:2024-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY007196171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist