Provider Demographics
NPI:1295107985
Name:DAVIS, MELINDA JOHNSON (MAED)
Entity type:Individual
Prefix:MRS
First Name:MELINDA
Middle Name:JOHNSON
Last Name:DAVIS
Suffix:
Gender:F
Credentials:MAED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:700 SAINT LANDRY ST
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70506-4630
Mailing Address - Country:US
Mailing Address - Phone:337-210-5145
Mailing Address - Fax:337-210-5450
Practice Address - Street 1:700 SAINT LANDRY ST
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70506
Practice Address - Country:US
Practice Address - Phone:337-210-5145
Practice Address - Fax:337-210-5450
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-21
Last Update Date:2019-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA600754073Medicaid