MEDICARE: SALLY MARCELLAIS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	172V00000X	Community Health Worker

General Provider Information

NPI Number	:	1396339446
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SALLY MARCELLAIS

Provider Business Mailing Address
First Line	:	PO BOX 952
Second Line	:
City	:	RAVENSWOOD
State	:	WV
Zip	:	26164-0952
Country	:	US
Telephone Number	:	304-273-9527
Fax Number	:

Provider Business Practice Location Address
First Line	:	1104 ANN ST
Second Line	:
City	:	RAVENSWOOD
State	:	WV
Zip	:	26164-1002
Country	:	US
Telephone Number	:	304-440-4000
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/01/2021
Last Update Date	:	03/01/2021

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Directions to “ SALLY MARCELLAIS ” Practice Location

Language	Start Address	Practice Location

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