Provider Demographics
NPI:1487318713
Name:CANCILLA, DOMENIC JOSEPH (PMHNP-BC)
Entity type:Individual
Prefix:
First Name:DOMENIC
Middle Name:JOSEPH
Last Name:CANCILLA
Suffix:
Gender:M
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2005 ASHLAND AVE
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43620-1703
Mailing Address - Country:US
Mailing Address - Phone:419-841-7701
Mailing Address - Fax:419-841-1691
Practice Address - Street 1:2005 ASHLAND AVE
Practice Address - Street 2:
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43620-1703
Practice Address - Country:US
Practice Address - Phone:419-841-7701
Practice Address - Fax:419-841-1691
Is Sole Proprietor?:No
Enumeration Date:2021-10-22
Last Update Date:2024-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAPRN.CNP.0030043363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health