Provider Demographics
NPI:1750405205
Name:ANETRELLA, MARYMIEL JOY (PT)
Entity type:Individual
Prefix:
First Name:MARYMIEL
Middle Name:JOY
Last Name:ANETRELLA
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:138 HENRIETTA AVE
Mailing Address - Street 2:
Mailing Address - City:OCEANSIDE
Mailing Address - State:NY
Mailing Address - Zip Code:11572-5226
Mailing Address - Country:US
Mailing Address - Phone:646-286-5038
Mailing Address - Fax:
Practice Address - Street 1:138 HENRIETTA AVE
Practice Address - Street 2:
Practice Address - City:OCEANSIDE
Practice Address - State:NY
Practice Address - Zip Code:11572-5226
Practice Address - Country:US
Practice Address - Phone:646-286-5038
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-19
Last Update Date:2022-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY023856225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02803950Medicaid
NYQ5W5U1Medicare ID - Type Unspecified