Provider Demographics
NPI:1821240748
Name:CANNELLA, DORI JO (RN)
Entity Type:Individual
Prefix:
First Name:DORI
Middle Name:JO
Last Name:CANNELLA
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:316 HAWKINS RD
Mailing Address - Street 2:
Mailing Address - City:CENTEREACH
Mailing Address - State:NY
Mailing Address - Zip Code:11720-1812
Mailing Address - Country:US
Mailing Address - Phone:631-946-6354
Mailing Address - Fax:
Practice Address - Street 1:316 HAWKINS RD
Practice Address - Street 2:
Practice Address - City:CENTEREACH
Practice Address - State:NY
Practice Address - Zip Code:11720-1812
Practice Address - Country:US
Practice Address - Phone:631-946-6354
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-10-22
Last Update Date:2008-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY498099-1163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY498099-1Medicaid