Provider Demographics
NPI:1083740872
Name:MITCHELL-MCCANN, MARLENA
Entity Type:Individual
Prefix:
First Name:MARLENA
Middle Name:
Last Name:MITCHELL-MCCANN
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 1:101 WINDERMERE CT
Mailing Address - Street 2:
Mailing Address - City:MC MURRAY
Mailing Address - State:PA
Mailing Address - Zip Code:15317-3671
Mailing Address - Country:US
Mailing Address - Phone:724-413-7572
Mailing Address - Fax:
Practice Address - Street 1:101 WINDERMERE CT
Practice Address - Street 2:
Practice Address - City:MC MURRAY
Practice Address - State:PA
Practice Address - Zip Code:15317-3671
Practice Address - Country:US
Practice Address - Phone:724-413-7572
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-26
Last Update Date:2023-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOEG001172152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0017603240003Medicaid
PA628353Medicare ID - Type Unspecified
PAU54946Medicare UPIN