Provider Demographics
NPI:1487890638
Name:CANNELLA, CHRISTOPHER (LO)
Entity type:Individual
Prefix:
First Name:CHRISTOPHER
Middle Name:
Last Name:CANNELLA
Suffix:
Gender:M
Credentials:LO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2385 BLACK ROCK TPKE
Mailing Address - Street 2:
Mailing Address - City:FAIRFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06825-3229
Mailing Address - Country:US
Mailing Address - Phone:203-372-7533
Mailing Address - Fax:203-372-6614
Practice Address - Street 1:2385 BLACK ROCK TPKE
Practice Address - Street 2:
Practice Address - City:FAIRFIELD
Practice Address - State:CT
Practice Address - Zip Code:06825-3229
Practice Address - Country:US
Practice Address - Phone:203-372-7533
Practice Address - Fax:203-372-6614
Is Sole Proprietor?:Yes
Enumeration Date:2008-12-17
Last Update Date:2008-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT1009156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician