Provider Demographics
NPI:1093128654
Name:TIANELLO, LOUELLA
Entity Type:Individual
Prefix:
First Name:LOUELLA
Middle Name:
Last Name:TIANELLO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:LOUELLA
Other - Middle Name:SUE
Other - Last Name:WOODWORTH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4831 STANLEY DR
Mailing Address - Street 2:
Mailing Address - City:OTTAWA LAKE
Mailing Address - State:MI
Mailing Address - Zip Code:49267-9611
Mailing Address - Country:US
Mailing Address - Phone:734-854-4504
Mailing Address - Fax:
Practice Address - Street 1:7358 SECOR RD
Practice Address - Street 2:
Practice Address - City:LAMBERTVILLE
Practice Address - State:MI
Practice Address - Zip Code:48144-9737
Practice Address - Country:US
Practice Address - Phone:734-856-7984
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-06-11
Last Update Date:2014-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302030060183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist