Provider Demographics
NPI:1730198029
Name:DALZELL, MARY-ELLEN (PA)
Entity type:Individual
Prefix:
First Name:MARY-ELLEN
Middle Name:
Last Name:DALZELL
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21 THOMSEN RD
Mailing Address - Street 2:
Mailing Address - City:HAMPTON
Mailing Address - State:NH
Mailing Address - Zip Code:03842-2073
Mailing Address - Country:US
Mailing Address - Phone:603-601-2718
Mailing Address - Fax:
Practice Address - Street 1:15 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:YORK
Practice Address - State:ME
Practice Address - Zip Code:03909-1011
Practice Address - Country:US
Practice Address - Phone:207-363-4321
Practice Address - Fax:207-351-2216
Is Sole Proprietor?:No
Enumeration Date:2006-08-05
Last Update Date:2016-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH0309363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH30332355Medicaid
NH30332355Medicaid
NH30332355Medicaid