Provider Demographics
NPI:1588830368
Name:ARELLANES, MARY ELLEN
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:ELLEN
Last Name:ARELLANES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:ELLEN
Other - Last Name:LISTER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPN
Mailing Address - Street 1:711 E MISSOURI AVE STE 110
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85014-2824
Mailing Address - Country:US
Mailing Address - Phone:602-604-0548
Mailing Address - Fax:
Practice Address - Street 1:711 E MISSOURI AVE STE 110
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85014-2824
Practice Address - Country:US
Practice Address - Phone:602-604-0548
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-05-01
Last Update Date:2008-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLP040638164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZLP040638OtherLPN