Provider Demographics
NPI:1104431469
Name:MARCELLUS, LINDA LEE
Entity type:Individual
Prefix:
First Name:LINDA
Middle Name:LEE
Last Name:MARCELLUS
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 1:15196 HARBOUR ISLE DR
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33908-6809
Mailing Address - Country:US
Mailing Address - Phone:330-283-6621
Mailing Address - Fax:
Practice Address - Street 1:15196 HARBOUR ISLE DR
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33908-6809
Practice Address - Country:US
Practice Address - Phone:330-283-6621
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-14
Last Update Date:2020-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH5200375Medicaid