Provider Demographics
NPI:1093066847
Name:FELLOWS, MARY LOU
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:LOU
Last Name:FELLOWS
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 1:14275 N COUNTY ROAD 24
Mailing Address - Street 2:
Mailing Address - City:WABASHA
Mailing Address - State:MN
Mailing Address - Zip Code:55981-7536
Mailing Address - Country:US
Mailing Address - Phone:651-560-2111
Mailing Address - Fax:
Practice Address - Street 1:14275 N COUNTY ROAD 24
Practice Address - Street 2:
Practice Address - City:WABASHA
Practice Address - State:MN
Practice Address - Zip Code:55981-7536
Practice Address - Country:US
Practice Address - Phone:651-560-2111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-09-19
Last Update Date:2012-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1054348 AFC372600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes372600000XNursing Service Related ProvidersAdult Companion