1275223117 NPI number — VALERY MARYELLEN SQUARE

Table of content: VALERY MARYELLEN SQUARE (NPI 1275223117)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1275223117 NPI number — VALERY MARYELLEN SQUARE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SQUARE
Provider First Name:
VALERY
Provider Middle Name:
MARYELLEN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1275223117
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/14/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
155 CONESTOGA ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
STEELTON
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
17113-2263
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
223-667-4238
Provider Business Mailing Address Fax Number:
717-828-4845

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
155 CONESTOGA ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
STEELTON
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
17113-2263
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
223-667-4238
Provider Business Practice Location Address Fax Number:
717-828-4845
Provider Enumeration Date:
05/12/2023

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 247000000X , registered in the state of LA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 372500000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3747P1801X , with the licence number: 96C08A27C81842EFBB39 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)