Provider Demographics
NPI:1447826086
Name:PISELLI, ANN MARIE
Entity type:Individual
Prefix:
First Name:ANN
Middle Name:MARIE
Last Name:PISELLI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 490
Mailing Address - Street 2:
Mailing Address - City:PENDERGRASS
Mailing Address - State:GA
Mailing Address - Zip Code:30567-0490
Mailing Address - Country:US
Mailing Address - Phone:937-231-4976
Mailing Address - Fax:
Practice Address - Street 1:1109 MEAD RD
Practice Address - Street 2:
Practice Address - City:BELLBROOK
Practice Address - State:OH
Practice Address - Zip Code:45305-8747
Practice Address - Country:US
Practice Address - Phone:937-620-1673
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-03
Last Update Date:2021-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH3747P1801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care AttendantGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0444398Medicaid