Healthcare Provider Details

I. General information

NPI: 1720521354
Provider Name (Legal Business Name): JESSICA CANALES
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/30/2016
Last Update Date: 08/21/2023
Certification Date: 08/21/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4845 ALAMEDA AVE
EL PASO TX
79905-2705
US

IV. Provider business mailing address

3230 DESTINY POINT DR
EL PASO TX
79938-5393
US

V. Phone/Fax

Practice location:
  • Phone: 915-298-5444
  • Fax:
Mailing address:
  • Phone: 915-253-2916
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WP0200X
TaxonomyPediatric Registered Nurse
License Number772023
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License NumberAP132668
License Number StateTX
# 3
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberAP132668
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: