Provider Demographics
NPI:1134463375
Name:CANCEL, IVELISSE YADIRA
Entity Type:Individual
Prefix:
First Name:IVELISSE
Middle Name:YADIRA
Last Name:CANCEL
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 1:77 BUTTERFIELD DR
Mailing Address - Street 2:
Mailing Address - City:PALM COAST
Mailing Address - State:FL
Mailing Address - Zip Code:32137-3517
Mailing Address - Country:US
Mailing Address - Phone:484-885-9335
Mailing Address - Fax:
Practice Address - Street 1:259 BILL FRANCE BLVD
Practice Address - Street 2:SUITE 200
Practice Address - City:DAYTONA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32114-1316
Practice Address - Country:US
Practice Address - Phone:484-885-9335
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-11
Last Update Date:2012-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator