Provider Demographics
NPI:1063035483
Name:IELLAMO, MARY ANNE
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:ANNE
Last Name:IELLAMO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:253 BURBANK RD
Mailing Address - Street 2:
Mailing Address - City:LONGMEADOW
Mailing Address - State:MA
Mailing Address - Zip Code:01106-1505
Mailing Address - Country:US
Mailing Address - Phone:413-530-5046
Mailing Address - Fax:
Practice Address - Street 1:3400 MAIN ST FL 2
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MA
Practice Address - Zip Code:01199-1003
Practice Address - Country:US
Practice Address - Phone:413-794-4681
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-20
Last Update Date:2020-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program