Provider Demographics
NPI:1093117103
Name:SCANNELLI, MARY
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:SCANNELLI
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 1:322 4TH ST NW
Mailing Address - Street 2:
Mailing Address - City:WINTER HAVEN
Mailing Address - State:FL
Mailing Address - Zip Code:33881-4671
Mailing Address - Country:US
Mailing Address - Phone:863-875-7959
Mailing Address - Fax:863-875-7960
Practice Address - Street 1:322 4TH ST NW
Practice Address - Street 2:
Practice Address - City:WINTER HAVEN
Practice Address - State:FL
Practice Address - Zip Code:33881-4671
Practice Address - Country:US
Practice Address - Phone:863-875-7959
Practice Address - Fax:863-875-7960
Is Sole Proprietor?:No
Enumeration Date:2014-09-19
Last Update Date:2014-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X, 172A00000X
FL233695376J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376J00000XNursing Service Related ProvidersHomemaker
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
No172A00000XOther Service ProvidersDriver