Provider Demographics
NPI:1376751339
Name:FELLER, MARY LYNNE
Entity type:Individual
Prefix:
First Name:MARY LYNNE
Middle Name:
Last Name:FELLER
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 1:10 LINCOLN DR
Mailing Address - Street 2:PO BOX 1243
Mailing Address - City:TUPPER LAKE
Mailing Address - State:NY
Mailing Address - Zip Code:12986-1517
Mailing Address - Country:US
Mailing Address - Phone:518-359-3311
Mailing Address - Fax:
Practice Address - Street 1:2445 STATE ROUTE 30
Practice Address - Street 2:
Practice Address - City:TUPPER LAKE
Practice Address - State:NY
Practice Address - Zip Code:12986-2502
Practice Address - Country:US
Practice Address - Phone:518-359-3311
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY002974-1363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant