Healthcare Provider Details

I. General information

NPI: 1578973616
Provider Name (Legal Business Name): INGRID MEJELLANO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/29/2014
Last Update Date: 04/29/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4922 LA SALLE ROAD
HYATTSVILLE MD
20782-3634
US

IV. Provider business mailing address

2400 QUEENS CHAPEL RD APT 810
HYATTSVILLE MD
20782-3634
US

V. Phone/Fax

Practice location:
  • Phone: 301-408-9046
  • Fax:
Mailing address:
  • Phone: 301-408-9046
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number23473
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: