Provider Demographics
NPI:1881777100
Name:CANULLAS, JENALYN
Entity type:Individual
Prefix:
First Name:JENALYN
Middle Name:
Last Name:CANULLAS
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 1:842 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:WEST LONG BRANCH
Mailing Address - State:NJ
Mailing Address - Zip Code:07764-1503
Mailing Address - Country:US
Mailing Address - Phone:732-222-0180
Mailing Address - Fax:732-222-3990
Practice Address - Street 1:842 BROADWAY
Practice Address - Street 2:
Practice Address - City:WEST LONG BRANCH
Practice Address - State:NJ
Practice Address - Zip Code:07764-1503
Practice Address - Country:US
Practice Address - Phone:732-222-0180
Practice Address - Fax:732-222-3990
Is Sole Proprietor?:No
Enumeration Date:2006-10-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NJ00073600363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJQ51866Medicare UPIN
094487UTIMedicare ID - Type Unspecified