Provider Demographics
NPI:1497599898
Name:DE MOTTA, MARYELLEN
Entity type:Individual
Prefix:
First Name:MARYELLEN
Middle Name:
Last Name:DE MOTTA
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 1:6229 OLYMPIC GOLD ST
Mailing Address - Street 2:
Mailing Address - City:NORTH LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89031-1190
Mailing Address - Country:US
Mailing Address - Phone:808-349-5447
Mailing Address - Fax:
Practice Address - Street 1:6229 OLYMPIC GOLD ST
Practice Address - Street 2:
Practice Address - City:NORTH LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89031-1190
Practice Address - Country:US
Practice Address - Phone:808-349-5447
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-06-20
Last Update Date:2024-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376J00000XNursing Service Related ProvidersHomemaker