Provider Demographics
NPI:1821546086
Name:PEALO, MARNIE
Entity Type:Individual
Prefix:
First Name:MARNIE
Middle Name:
Last Name:PEALO
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 1:14 MAIDEN LN
Mailing Address - Street 2:
Mailing Address - City:PENN YAN
Mailing Address - State:NY
Mailing Address - Zip Code:14527-1208
Mailing Address - Country:US
Mailing Address - Phone:315-531-9102
Mailing Address - Fax:315-531-9103
Practice Address - Street 1:7150 MAIN ST
Practice Address - Street 2:
Practice Address - City:OVID
Practice Address - State:NY
Practice Address - Zip Code:14521-9401
Practice Address - Country:US
Practice Address - Phone:607-403-0065
Practice Address - Fax:607-403-0093
Is Sole Proprietor?:No
Enumeration Date:2016-09-16
Last Update Date:2016-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY291135164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY291135OtherLICENSE