Provider Demographics
NPI:1508838616
Name:NEAL, MARYELLEN (ARNP)
Entity Type:Individual
Prefix:MRS
First Name:MARYELLEN
Middle Name:
Last Name:NEAL
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2896 GULF BREEZE PKWY
Mailing Address - Street 2:
Mailing Address - City:GULF BREEZE
Mailing Address - State:FL
Mailing Address - Zip Code:32563-3146
Mailing Address - Country:US
Mailing Address - Phone:850-932-2203
Mailing Address - Fax:850-934-0050
Practice Address - Street 1:1354 COUNTRY CLUB RD
Practice Address - Street 2:
Practice Address - City:GULF BREEZE
Practice Address - State:FL
Practice Address - Zip Code:32563-3471
Practice Address - Country:US
Practice Address - Phone:850-916-1636
Practice Address - Fax:850-916-1350
Is Sole Proprietor?:No
Enumeration Date:2006-02-02
Last Update Date:2017-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1704722363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLY8704YMedicare ID - Type Unspecified