Provider Demographics
NPI:1093110678
Name:RELYEA, MARK A (LPN)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:A
Last Name:RELYEA
Suffix:
Gender:M
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8145 OLDBURY RD
Mailing Address - Street 2:
Mailing Address - City:LIVERPOOL
Mailing Address - State:NY
Mailing Address - Zip Code:13090-1601
Mailing Address - Country:US
Mailing Address - Phone:315-761-6135
Mailing Address - Fax:
Practice Address - Street 1:8145 OLDBURY RD
Practice Address - Street 2:
Practice Address - City:LIVERPOOL
Practice Address - State:NY
Practice Address - Zip Code:13090-1601
Practice Address - Country:US
Practice Address - Phone:315-761-6135
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-25
Last Update Date:2014-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY8296248164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse