Provider Demographics
NPI:1992127674
Name:JOHNSON, MELISSA (CNM)
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:401 E 6TH ST
Mailing Address - Street 2:
Mailing Address - City:ODESSA
Mailing Address - State:TX
Mailing Address - Zip Code:79761-4516
Mailing Address - Country:US
Mailing Address - Phone:432-582-2280
Mailing Address - Fax:432-331-9981
Practice Address - Street 1:401 E 6TH ST
Practice Address - Street 2:
Practice Address - City:ODESSA
Practice Address - State:TX
Practice Address - Zip Code:79761-4516
Practice Address - Country:US
Practice Address - Phone:432-582-2280
Practice Address - Fax:432-331-9981
Is Sole Proprietor?:No
Enumeration Date:2014-01-14
Last Update Date:2018-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP125094367A00000X
TX785789363LX0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LX0001XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerObstetrics & Gynecology
No367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife