Provider Demographics
NPI:1699309575
Name:JOHNSON, MELISSA ALICE (FNP)
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:ALICE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3 TECHNOLOGY DR
Mailing Address - Street 2:
Mailing Address - City:EAST SETAUKET
Mailing Address - State:NY
Mailing Address - Zip Code:11733-4064
Mailing Address - Country:US
Mailing Address - Phone:631-444-5220
Mailing Address - Fax:
Practice Address - Street 1:120 MINEOLA BLVD STE 100
Practice Address - Street 2:
Practice Address - City:MINEOLA
Practice Address - State:NY
Practice Address - Zip Code:11501-4077
Practice Address - Country:US
Practice Address - Phone:516-663-3010
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-28
Last Update Date:2022-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY345498363LF0000X
NYF345498-01363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily