Provider Demographics
NPI:1407107469
Name:MARCELLUS, LAURIE A (LPN)
Entity Type:Individual
Prefix:
First Name:LAURIE
Middle Name:A
Last Name:MARCELLUS
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 1:428 STATE HIGHWAY 29
Mailing Address - Street 2:
Mailing Address - City:BROADALBIN
Mailing Address - State:NY
Mailing Address - Zip Code:12025-1957
Mailing Address - Country:US
Mailing Address - Phone:518-883-5366
Mailing Address - Fax:
Practice Address - Street 1:428 STATE HIGHWAY 29
Practice Address - Street 2:
Practice Address - City:BROADALBIN
Practice Address - State:NY
Practice Address - Zip Code:12025-1957
Practice Address - Country:US
Practice Address - Phone:518-883-5366
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-30
Last Update Date:2012-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY277169-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse