Provider Demographics
NPI:1134447030
Name:AMOLI, MARIELLE AMELI (MD)
Entity type:Individual
Prefix:
First Name:MARIELLE
Middle Name:AMELI
Last Name:AMOLI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:MARIELLE
Other - Middle Name:
Other - Last Name:CONNOR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:10140 CENTURION PKWY N
Mailing Address - Street 2:PROVIDER ENROLLMENT
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32256-0532
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:807 CHILDRENS WAY
Practice Address - Street 2:NEMOURS CHILDRENS SPECIALTY CARE, JACKSONVILLE
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32207-8426
Practice Address - Country:US
Practice Address - Phone:904-697-3600
Practice Address - Fax:904-697-3927
Is Sole Proprietor?:No
Enumeration Date:2010-05-17
Last Update Date:2018-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME126475207XP3100X
FLTRN14929207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XP3100XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryPediatric Orthopaedic Surgery
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL018556000Medicaid