Provider Demographics
NPI:1659741627
Name:CANOLE, JIMMIE DEAN
Entity Type:Individual
Prefix:MR
First Name:JIMMIE
Middle Name:DEAN
Last Name:CANOLE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2979 S HWY A1A
Mailing Address - Street 2:UNIT 224
Mailing Address - City:MELBOURNE BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32951-2881
Mailing Address - Country:US
Mailing Address - Phone:321-223-9822
Mailing Address - Fax:321-723-7720
Practice Address - Street 1:2979 S HWY A1A
Practice Address - Street 2:UNIT 224
Practice Address - City:MELBOURNE BEACH
Practice Address - State:FL
Practice Address - Zip Code:32951-2881
Practice Address - Country:US
Practice Address - Phone:321-223-9822
Practice Address - Fax:321-723-7720
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-02
Last Update Date:2015-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLA039719251X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251X00000XAgenciesSupports Brokerage
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL573494OtherNATIONAL PRODUCER NUMBER