Provider Demographics
NPI:1871774182
Name:MONGELLUZZO, LOUISE ANN (PA-C)
Entity type:Individual
Prefix:MRS
First Name:LOUISE
Middle Name:ANN
Last Name:MONGELLUZZO
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:52 ARTILLERY LN
Mailing Address - Street 2:
Mailing Address - City:BALDWINSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:13027-1146
Mailing Address - Country:US
Mailing Address - Phone:315-652-3518
Mailing Address - Fax:
Practice Address - Street 1:52 ARTILLERY LN
Practice Address - Street 2:
Practice Address - City:BALDWINSVILLE
Practice Address - State:NY
Practice Address - Zip Code:13027-1146
Practice Address - Country:US
Practice Address - Phone:315-652-3518
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-15
Last Update Date:2007-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY008973-1363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical