Provider Demographics
NPI:1962670414
Name:CANALES, DASIA JULISA
Entity Type:Individual
Prefix:
First Name:DASIA
Middle Name:JULISA
Last Name:CANALES
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 1:1855 AMES BLVD
Mailing Address - Street 2:
Mailing Address - City:MARRERO
Mailing Address - State:LA
Mailing Address - Zip Code:70072-3429
Mailing Address - Country:US
Mailing Address - Phone:504-371-8958
Mailing Address - Fax:
Practice Address - Street 1:1855 AMES BLVD
Practice Address - Street 2:
Practice Address - City:MARRERO
Practice Address - State:LA
Practice Address - Zip Code:70072-3429
Practice Address - Country:US
Practice Address - Phone:504-371-8958
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-02-19
Last Update Date:2008-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA1976133N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133N00000XDietary & Nutritional Service ProvidersNutritionist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1454117Medicaid
LA5CM83Medicare PIN