Provider Demographics
NPI:1750729224
Name:STEPHENS, MARYELLEN (RN MS PMHNP)
Entity type:Individual
Prefix:
First Name:MARYELLEN
Middle Name:
Last Name:STEPHENS
Suffix:
Gender:F
Credentials:RN MS PMHNP
Other - Prefix:
Other - First Name:
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Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2520 GENESEE ST
Mailing Address - Street 2:
Mailing Address - City:UTICA
Mailing Address - State:NY
Mailing Address - Zip Code:13502-5814
Mailing Address - Country:US
Mailing Address - Phone:315-272-2129
Mailing Address - Fax:315-272-2177
Practice Address - Street 1:2520 GENESEE ST
Practice Address - Street 2:
Practice Address - City:UTICA
Practice Address - State:NY
Practice Address - Zip Code:13502-5814
Practice Address - Country:US
Practice Address - Phone:315-272-2129
Practice Address - Fax:315-272-2177
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-06
Last Update Date:2023-04-20
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY40-401595363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health