Healthcare Provider Details

I. General information

NPI: 1154443117
Provider Name (Legal Business Name): WYNNELENA CANLAS CANIO M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/03/2007
Last Update Date: 12/15/2021
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

401 BICENTENNIAL WAY
SANTA ROSA CA
95403-2149
US

IV. Provider business mailing address

401 BICENTENNIAL WAY
SANTA ROSA CA
95403-2149
US

V. Phone/Fax

Practice location:
  • Phone: 707-393-3274
  • Fax:
Mailing address:
  • Phone: 707-393-3274
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0300X
TaxonomyGeriatric Medicine (Internal Medicine) Physician
License NumberA108488
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberA108488
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: