Provider Demographics
NPI:1063742542
Name:JOHNSON, MELISA TAYLOR (RN)
Entity type:Individual
Prefix:
First Name:MELISA
Middle Name:TAYLOR
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8240 W LANCASTER AVE
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53218-3654
Mailing Address - Country:US
Mailing Address - Phone:414-531-7582
Mailing Address - Fax:
Practice Address - Street 1:8240 W LANCASTER AVE
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53218-3654
Practice Address - Country:US
Practice Address - Phone:414-531-7582
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-01-06
Last Update Date:2010-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI160448-30163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse