Healthcare Provider Details

I. General information

NPI: 1063501369
Provider Name (Legal Business Name): ANGELA MARIE CANCELLIERI D.C.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/12/2006
Last Update Date: 02/13/2025
Certification Date: 02/13/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4945 LAKE AVE
BLASDELL NY
14219-1313
US

IV. Provider business mailing address

4945 LAKE AVE
BLASDELL NY
14219-1313
US

V. Phone/Fax

Practice location:
  • Phone: 631-495-4302
  • Fax:
Mailing address:
  • Phone: 631-495-4302
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License NumberX-005472-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: