Provider Demographics
NPI:1376188219
Name:MARINELLI, NICHOLAS RAYMOND
Entity Type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:RAYMOND
Last Name:MARINELLI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2354 MENDENHALL LOOP RD STE 79
Mailing Address - Street 2:
Mailing Address - City:JUNEAU
Mailing Address - State:AK
Mailing Address - Zip Code:99801-8001
Mailing Address - Country:US
Mailing Address - Phone:907-500-7456
Mailing Address - Fax:
Practice Address - Street 1:2354 MENDENHALL LOOP RD STE 79
Practice Address - Street 2:
Practice Address - City:JUNEAU
Practice Address - State:AK
Practice Address - Zip Code:99801-8001
Practice Address - Country:US
Practice Address - Phone:907-500-7456
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-14
Last Update Date:2021-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator