Provider Demographics
NPI:1508285347
Name:MCCLELLAN-VELEZ, MARY LOU
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:LOU
Last Name:MCCLELLAN-VELEZ
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 1:265A CLIFTON AVE FL 1
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10305-1601
Mailing Address - Country:US
Mailing Address - Phone:718-524-5400
Mailing Address - Fax:
Practice Address - Street 1:265A CLIFTON AVE FL 1
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10305-1601
Practice Address - Country:US
Practice Address - Phone:718-524-5400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-09
Last Update Date:2014-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY3174061164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse