Healthcare Provider Details

I. General information

NPI: 1548613623
Provider Name (Legal Business Name): DENISE CANELLOS MS, CNS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/13/2016
Last Update Date: 07/13/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4000 BARRANCA PKWY SUITE 250
IRVINE CA
92604-4710
US

IV. Provider business mailing address

4000 BARRANCA PKWY SUITE 250
IRVINE CA
92604-4710
US

V. Phone/Fax

Practice location:
  • Phone: 949-681-8261
  • Fax:
Mailing address:
  • Phone: 949-681-8261
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133NN1002X
TaxonomyNutrition Education Nutritionist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: