=====================================================
General NPI Number Information
=====================================================
NPI Number | 1134447030
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARIELLE AMELI AMOLI MD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/17/2010
-----------------------------------------------------
Last Update Date | 01/03/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 807 CHILDRENS WAY NEMOURS CHILDRENS SPECIALTY CARE, JACKSONVILLE
-----------------------------------------------------
City | JACKSONVILLE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32207-8426
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-697-3600
-----------------------------------------------------
Fax | 904-697-3927
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10140 CENTURION PKWY N PROVIDER ENROLLMENT
-----------------------------------------------------
City | JACKSONVILLE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32256-0532
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207XP3100X
-----------------------------------------------------
Taxonomy Name | Pediatric Orthopaedic Surgery Physician
-----------------------------------------------------
License Number | ME126475
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207X00000X
-----------------------------------------------------
Taxonomy Name | Orthopaedic Surgery Physician
-----------------------------------------------------
License Number | TRN14929
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------