Basic Information
| Provider Information | |||||||||
| NPI: | 1699309575 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JOHNSON | ||||||||
| FirstName: | MELISSA | ||||||||
| MiddleName: | ALICE | ||||||||
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| Credential: | FNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3 TECHNOLOGY DR | ||||||||
| Address2: | |||||||||
| City: | EAST SETAUKET | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117334064 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6314445220 | ||||||||
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| Practice Location | |||||||||
| Address1: | 120 MINEOLA BLVD STE 100 | ||||||||
| Address2: | |||||||||
| City: | MINEOLA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 115014077 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5166633010 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/28/2020 | ||||||||
| LastUpdateDate: | 01/12/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/31/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 345498 | NY | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LF0000X | F345498-01 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.