Provider Demographics
NPI:1528542701
Name:MARMOLEJOS, SHANELY
Entity Type:Individual
Prefix:
First Name:SHANELY
Middle Name:
Last Name:MARMOLEJOS
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 1:57 EUCLID AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11208-1411
Mailing Address - Country:US
Mailing Address - Phone:914-689-4246
Mailing Address - Fax:
Practice Address - Street 1:61 BRADFORD ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11207-2501
Practice Address - Country:US
Practice Address - Phone:866-972-5877
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-24
Last Update Date:2018-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator