Provider Demographics
NPI:1841562485
Name:MAIELLO, WENDY
Entity Type:Individual
Prefix:
First Name:WENDY
Middle Name:
Last Name:MAIELLO
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 1:61 MANN AVE
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10314-4421
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:260 ARDEN AVE
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10312-1229
Practice Address - Country:US
Practice Address - Phone:718-966-5509
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-28
Last Update Date:2012-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY20 049604183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist