Basic Information
| Provider Information | |||||||||
| NPI: | 1518080191 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | COTELLESE | ||||||||
| FirstName: | MARYELLEN | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1364 | ||||||||
| Address2: | |||||||||
| City: | RADFORD | ||||||||
| State: | VA | ||||||||
| PostalCode: | 241431364 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5406335650 | ||||||||
| FaxNumber: | 5406331524 | ||||||||
| Practice Location | |||||||||
| Address1: | 2900 LAMB CIR STE 335 | ||||||||
| Address2: | |||||||||
| City: | CHRISTIANSBURG | ||||||||
| State: | VA | ||||||||
| PostalCode: | 240736341 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5406335650 | ||||||||
| FaxNumber: | 5406331524 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/09/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP2300X | 0024090106 | VA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Primary Care |
ID Information
| ID | Type | State | Issuer | Description | 7794126 | 05 | VA | MEDICAID |