Provider Demographics
NPI:1003401811
Name:CANCELLO, DEANNA MARIE (RDN)
Entity Type:Individual
Prefix:
First Name:DEANNA
Middle Name:MARIE
Last Name:CANCELLO
Suffix:
Gender:F
Credentials:RDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2420 RAVINE WAY STE 400
Mailing Address - Street 2:
Mailing Address - City:GLENVIEW
Mailing Address - State:IL
Mailing Address - Zip Code:60025-7651
Mailing Address - Country:US
Mailing Address - Phone:647-686-4444
Mailing Address - Fax:
Practice Address - Street 1:2420 RAVINE WAY STE 400
Practice Address - Street 2:
Practice Address - City:GLENVIEW
Practice Address - State:IL
Practice Address - Zip Code:60025-7651
Practice Address - Country:US
Practice Address - Phone:647-686-4444
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-03
Last Update Date:2021-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL86098532133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered