Provider Demographics
NPI:1396855110
Name:MOMORELLA, JEAN TANI (MSPT)
Entity type:Individual
Prefix:MRS
First Name:JEAN
Middle Name:TANI
Last Name:MOMORELLA
Suffix:
Gender:F
Credentials:MSPT
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:659 S SALISBURY BLVD STE 1B
Mailing Address - Street 2:
Mailing Address - City:SALISBURY
Mailing Address - State:MD
Mailing Address - Zip Code:21801-5458
Mailing Address - Country:US
Mailing Address - Phone:410-831-3226
Mailing Address - Fax:410-572-4041
Practice Address - Street 1:21 W CLARKE AVE STE 1500
Practice Address - Street 2:
Practice Address - City:MILFORD
Practice Address - State:DE
Practice Address - Zip Code:19963-1857
Practice Address - Country:US
Practice Address - Phone:302-491-6529
Practice Address - Fax:302-503-7160
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2023-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEJ1-0014558225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
192545OtherANTHEM BC/BS
VA304084OtherANTHEM BC/BS
VA304084OtherANTHEM BC/BS
192545OtherANTHEM BC/BS