Provider Demographics
NPI:1184609752
Name:JOHNSON MELTON, TAMMY LYNNE (FNP-C)
Entity type:Individual
Prefix:MRS
First Name:TAMMY
Middle Name:LYNNE
Last Name:JOHNSON MELTON
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:MS
Other - First Name:TAMMY
Other - Middle Name:JOHNSON
Other - Last Name:MELTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:FNP-C
Mailing Address - Street 1:PO BOX 60447
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-0447
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6324 FAIRVIEW RD STE 310
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28210-4172
Practice Address - Country:US
Practice Address - Phone:980-302-8680
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-07
Last Update Date:2021-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC90293163W00000X
NC201712363LF0000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
611186890Other611186890
NC5950066Medicaid
611186890OtherBEECH STREET
NP0682OtherSC MEDICAID
012U9OtherBCBS NC
611186890OtherCIGNA HEALTHCARE
611186890OtherCRESENT
C4367OtherMEDCOST
611186890OtherPRIVATE HEALTHCARE SYSTEM
611186890OtherFIRST HEALTH
NC7003522Medicaid
0171701OtherUNITED HEALTHCARE
611186890OtherHUMANA/TRICARE
611186890OtherHUMANA/TRICARE
611186890Other611186890