Provider Demographics
NPI:1124630884
Name:CANNISTRA, DANIELLE
Entity type:Individual
Prefix:
First Name:DANIELLE
Middle Name:
Last Name:CANNISTRA
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 1:101 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:HAMMONTON
Mailing Address - State:NJ
Mailing Address - Zip Code:08037-1103
Mailing Address - Country:US
Mailing Address - Phone:609-513-6140
Mailing Address - Fax:
Practice Address - Street 1:101 BROADWAY
Practice Address - Street 2:
Practice Address - City:HAMMONTON
Practice Address - State:NJ
Practice Address - Zip Code:08037-1103
Practice Address - Country:US
Practice Address - Phone:609-513-6140
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-23
Last Update Date:2020-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QB00374600225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant