Healthcare Provider Details

I. General information

NPI: 1083403489
Provider Name (Legal Business Name): ALEXANDRA MARIE MARCELLO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/02/2025
Last Update Date: 12/16/2025
Certification Date: 12/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1222 TOWN COLONY DR
MIDDLETOWN CT
06457-5927
US

IV. Provider business mailing address

1811 FREDERICK AVE
MERRICK NY
11566-2911
US

V. Phone/Fax

Practice location:
  • Phone: 516-492-1807
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number754344
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code163WC0200X
TaxonomyCritical Care Medicine Registered Nurse
License Number202914
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: