Provider Demographics
NPI:1518080191
Name:COTELLESE, MARYELLEN M
Entity Type:Individual
Prefix:MRS
First Name:MARYELLEN
Middle Name:M
Last Name:COTELLESE
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:PO BOX 1364
Mailing Address - Street 2:
Mailing Address - City:RADFORD
Mailing Address - State:VA
Mailing Address - Zip Code:24143-1364
Mailing Address - Country:US
Mailing Address - Phone:540-633-5650
Mailing Address - Fax:540-633-1524
Practice Address - Street 1:2900 LAMB CIR STE 335
Practice Address - Street 2:
Practice Address - City:CHRISTIANSBURG
Practice Address - State:VA
Practice Address - Zip Code:24073-6341
Practice Address - Country:US
Practice Address - Phone:540-633-5650
Practice Address - Fax:540-633-1524
Is Sole Proprietor?:No
Enumeration Date:2007-04-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024090106363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA7794126Medicaid