Provider Demographics
NPI:1104559996
Name:SALLEE, MARY ELISE
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:ELISE
Last Name:SALLEE
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 1:539 BELLWOOD DR APT B
Mailing Address - Street 2:
Mailing Address - City:ELIZABETHTOWN
Mailing Address - State:KY
Mailing Address - Zip Code:42701-2337
Mailing Address - Country:US
Mailing Address - Phone:270-312-2500
Mailing Address - Fax:
Practice Address - Street 1:539 BELLWOOD DR APT B
Practice Address - Street 2:
Practice Address - City:ELIZABETHTOWN
Practice Address - State:KY
Practice Address - Zip Code:42701-2337
Practice Address - Country:US
Practice Address - Phone:270-312-2500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-08
Last Update Date:2022-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY175T00000X
175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist