Provider Demographics
NPI:1336758259
Name:CANNELLA, NICOLE
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:CANNELLA
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 1:172 NW WILLOW GROVE AVE
Mailing Address - Street 2:
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34986-3566
Mailing Address - Country:US
Mailing Address - Phone:772-985-8084
Mailing Address - Fax:
Practice Address - Street 1:1765 SW CAPTAINS PL
Practice Address - Street 2:
Practice Address - City:PALM CITY
Practice Address - State:FL
Practice Address - Zip Code:34990-1747
Practice Address - Country:US
Practice Address - Phone:772-266-8727
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-27
Last Update Date:2020-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-20-115823106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician