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General NPI Number Information
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NPI Number | 1063026110
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Entity Type | Individual
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Provider Name | MARYELLEN TUSSEY NP
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Gender | Female
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Dates
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Enumeration Date | 09/06/2020
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Last Update Date | 08/02/2024
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Provider Practice Location Address
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Address Line | 207 N CAROL MALONE BLVD STE 3
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City | GRAYSON
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State | KY
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Zip | 41143-1566
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Country | US
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Telephone | 606-225-8200
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Fax | 888-606-7354
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Provider Business Mailing Address
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Address Line | 207 N CAROL MALONE BLVD STE 3
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City | GRAYSON
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State | KY
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Zip | 41143-1566
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Country | US
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Telephone | 606-225-8200
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Fax | 888-606-7354
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number | 3015040
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License Number State | KY
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