Provider Demographics
NPI:1326229071
Name:CANNELLA, REGINA (COTA/L)
Entity Type:Individual
Prefix:
First Name:REGINA
Middle Name:
Last Name:CANNELLA
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:97 WOODSIDE DR
Mailing Address - Street 2:
Mailing Address - City:PALM COAST
Mailing Address - State:FL
Mailing Address - Zip Code:32164-7995
Mailing Address - Country:US
Mailing Address - Phone:206-931-2387
Mailing Address - Fax:
Practice Address - Street 1:97 WOODSIDE DR
Practice Address - Street 2:
Practice Address - City:PALM COAST
Practice Address - State:FL
Practice Address - Zip Code:32164-7995
Practice Address - Country:US
Practice Address - Phone:206-931-2387
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-23
Last Update Date:2007-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOTA10574171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor