Provider Demographics
NPI:1154534949
Name:JOHNSON, MELISSA ERIN (PT)
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:ERIN
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:MELISSA
Other - Middle Name:JOHNSON
Other - Last Name:MCKINNISS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PT
Mailing Address - Street 1:1155 35TH LN
Mailing Address - Street 2:SUITE 100
Mailing Address - City:VERO BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32960-6521
Mailing Address - Country:US
Mailing Address - Phone:772-569-2330
Mailing Address - Fax:772-569-2630
Practice Address - Street 1:1155 35TH LN
Practice Address - Street 2:
Practice Address - City:VERO BEACH
Practice Address - State:FL
Practice Address - Zip Code:32960-6521
Practice Address - Country:US
Practice Address - Phone:772-569-2330
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-08
Last Update Date:2013-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT 20032225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLFW691ZMedicare UPIN