Provider Demographics
NPI:1467643049
Name:FERNELIS, MARIE G
Entity Type:Individual
Prefix:MRS
First Name:MARIE
Middle Name:G
Last Name:FERNELIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8411 MAYMEADOW CT
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21244-2148
Mailing Address - Country:US
Mailing Address - Phone:410-521-4333
Mailing Address - Fax:
Practice Address - Street 1:8411 MAYMEADOW CT
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21244-2148
Practice Address - Country:US
Practice Address - Phone:410-521-4333
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-07
Last Update Date:2007-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD03AL0834310400000X
MD30AL2941310400000X
MD03AL0888310400000X
MD03AL0973310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility