Provider Demographics
NPI:1235520131
Name:PELLERANO, MYRNA (BA)
Entity Type:Individual
Prefix:
First Name:MYRNA
Middle Name:
Last Name:PELLERANO
Suffix:
Gender:F
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1401 PARKMOOR AVE
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95126-3403
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1887 MONTEREY ROAD
Practice Address - Street 2:SUITE 205
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95112
Practice Address - Country:US
Practice Address - Phone:646-247-6335
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-02-12
Last Update Date:2018-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker