Provider Demographics
NPI:1609021187
Name:CANALE, JENNIFER DIANA (NP)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:DIANA
Last Name:CANALE
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:436 PARKVIEW PLACE DR
Mailing Address - Street 2:
Mailing Address - City:ELLISVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:63021-4642
Mailing Address - Country:US
Mailing Address - Phone:636-207-7870
Mailing Address - Fax:
Practice Address - Street 1:17300 N OUTER 40
Practice Address - Street 2:SUITE 100
Practice Address - City:CHESTERFIELD
Practice Address - State:MO
Practice Address - Zip Code:63005-1364
Practice Address - Country:US
Practice Address - Phone:636-519-8889
Practice Address - Fax:636-536-0120
Is Sole Proprietor?:No
Enumeration Date:2008-11-25
Last Update Date:2008-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2002005070363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner