Healthcare Provider Details

I. General information

NPI: 1093128654
Provider Name (Legal Business Name): LOUELLA TIANELLO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: LOUELLA SUE WOODWORTH

II. Dates (important events)

Enumeration Date: 06/11/2014
Last Update Date: 06/11/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7358 SECOR RD
LAMBERTVILLE MI
48144-9737
US

IV. Provider business mailing address

4831 STANLEY DR
OTTAWA LAKE MI
49267-9611
US

V. Phone/Fax

Practice location:
  • Phone: 734-856-7984
  • Fax:
Mailing address:
  • Phone: 734-854-4504
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number5302030060
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: