Provider Demographics
NPI:1023791803
Name:CANNELLA, NICOLE MICHELLE (COTA/L)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:MICHELLE
Last Name:CANNELLA
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:108 NE 16TH AVE APT 406
Mailing Address - Street 2:
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33301-3842
Mailing Address - Country:US
Mailing Address - Phone:954-459-5106
Mailing Address - Fax:
Practice Address - Street 1:108 NE 16TH AVE APT 406
Practice Address - Street 2:
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33301-3842
Practice Address - Country:US
Practice Address - Phone:954-459-5106
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-09
Last Update Date:2023-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL19601224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant