Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 363L00000X | Nurse Practitioner | APRN001367 | NV |
Y | 363LF0000X | Nurse Practitioner - Family Medicine | APRN001367 | NV |
NPI | 1003181926 |
---|---|
Provider Name | Mellyn Aileen Johnson |
First Address | Reno, NV 89502-2055 |
Second Address | Reno, NV 89502-1262 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 09/03/2012 |
Last Update Date | 22/04/2019 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
1003181926 | (05) | NV |
12368895 | CAQH (01) |