Provider Demographics
NPI:1427271907
Name:JOHNSON, MELODY MARIE (PA-C)
Entity type:Individual
Prefix:MRS
First Name:MELODY
Middle Name:MARIE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1117 W SEAGATE DR
Mailing Address - Street 2:
Mailing Address - City:DELTONA
Mailing Address - State:FL
Mailing Address - Zip Code:32725-2214
Mailing Address - Country:US
Mailing Address - Phone:407-862-1163
Mailing Address - Fax:407-774-1877
Practice Address - Street 1:357 WEKIVA SPRINGS RD
Practice Address - Street 2:
Practice Address - City:LONGWOOD
Practice Address - State:FL
Practice Address - Zip Code:32779-3607
Practice Address - Country:US
Practice Address - Phone:407-862-1163
Practice Address - Fax:407-774-1877
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL3320363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant