Provider Demographics
NPI:1255896338
Name:JOHNSON, MELISSA FAYE (APRN)
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:FAYE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:MELISSA
Other - Middle Name:FAYE
Other - Last Name:MCFANN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 2379
Mailing Address - Street 2:
Mailing Address - City:ASHLAND
Mailing Address - State:KY
Mailing Address - Zip Code:41105-2379
Mailing Address - Country:US
Mailing Address - Phone:606-408-6200
Mailing Address - Fax:606-408-6612
Practice Address - Street 1:617 23RD ST STE 400
Practice Address - Street 2:
Practice Address - City:ASHLAND
Practice Address - State:KY
Practice Address - Zip Code:41101-2880
Practice Address - Country:US
Practice Address - Phone:606-408-2820
Practice Address - Fax:606-329-1768
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-04
Last Update Date:2021-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3013115363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100577050Medicaid