Basic Information
| Provider Information | |||||||||
| NPI: | 1619440971 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CANELLOS | ||||||||
| FirstName: | DEBRA | ||||||||
| MiddleName: | KAY | ||||||||
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| Credential: | CRNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1201 GRAMPIAN BLVD | ||||||||
| Address2: | |||||||||
| City: | WILLIAMSPORT | ||||||||
| State: | PA | ||||||||
| PostalCode: | 177011900 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5703268723 | ||||||||
| FaxNumber: | 5703268540 | ||||||||
| Practice Location | |||||||||
| Address1: | 700 HIGH STREET | ||||||||
| Address2: | |||||||||
| City: | WILLIAMSPORT | ||||||||
| State: | PA | ||||||||
| PostalCode: | 177013198 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5703213580 | ||||||||
| FaxNumber: | 5703213581 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/09/2019 | ||||||||
| LastUpdateDate: | 01/09/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | SP019590 | PA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.