Healthcare Provider Details

I. General information

NPI: 1063839546
Provider Name (Legal Business Name): MELISSA JOHNSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/24/2014
Last Update Date: 03/24/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

881 USS JAMES MADISON RD
KINGS BAY GA
31547-2531
US

IV. Provider business mailing address

881 USS JAMES MADISON RD
KINGS BAY GA
31547-2531
US

V. Phone/Fax

Practice location:
  • Phone: 912-573-0511
  • Fax:
Mailing address:
  • Phone: 912-573-0511
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WX0106X
TaxonomyOccupational Health Registered Nurse
License NumberRN174049
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: