MEDICARE: MELISSA JOHANSEN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	376K00000X	Nurse's Aide
2	374U00000X	Home Health Aide

General Provider Information

NPI Number	:	1790512960
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MELISSA JOHANSEN

Provider Business Mailing Address
First Line	:	3722 OLD VILLAGE WAY
Second Line	:
City	:	OLDSMAR
State	:	FL
Zip	:	34677-5048
Country	:	US
Telephone Number	:	727-219-7808
Fax Number	:

Provider Business Practice Location Address
First Line	:	3722 OLD VILLAGE WAY
Second Line	:
City	:	OLDSMAR
State	:	FL
Zip	:	34677-5048
Country	:	US
Telephone Number	:	727-219-7808
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/19/2024
Last Update Date	:	09/19/2024

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Directions to “ MELISSA JOHANSEN ” Practice Location

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