Provider Demographics
NPI:1316376718
Name:DEMELLA, MADONNA (LPN)
Entity Type:Individual
Prefix:
First Name:MADONNA
Middle Name:
Last Name:DEMELLA
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:54 DOGWOOD LN
Mailing Address - Street 2:
Mailing Address - City:MANORVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:11949-3111
Mailing Address - Country:US
Mailing Address - Phone:631-294-0789
Mailing Address - Fax:
Practice Address - Street 1:51 TALL OAK CIR
Practice Address - Street 2:APARTMENT #1
Practice Address - City:MORICHES
Practice Address - State:NY
Practice Address - Zip Code:11955-1105
Practice Address - Country:US
Practice Address - Phone:631-294-0789
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-06
Last Update Date:2013-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY10280398164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse