Healthcare Provider Details

I. General information

NPI: 1578315057
Provider Name (Legal Business Name): MELINDA P JOHANSEN RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/05/2024
Last Update Date: 04/09/2024
Certification Date: 04/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

405 N WABASH AVE UNIT 4403
CHICAGO IL
60611-3527
US

IV. Provider business mailing address

405 N WABASH AVE UNIT 4403
CHICAGO IL
60611-3527
US

V. Phone/Fax

Practice location:
  • Phone: 312-955-8787
  • Fax: 312-955-8789
Mailing address:
  • Phone: 312-955-8787
  • Fax: 312-955-8789

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number041.430210
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: