Healthcare Provider Details

I. General information

NPI: 1972380913
Provider Name (Legal Business Name): ANGELA CANNAVO CNS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/13/2023
Last Update Date: 12/23/2024
Certification Date: 12/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3903 FAIR RIDGE DR
FAIRFAX VA
22033-2943
US

IV. Provider business mailing address

3531 GEORGIA AVE NW
WASHINGTON DC
20010-1707
US

V. Phone/Fax

Practice location:
  • Phone: 703-865-6490
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133N00000X
TaxonomyNutritionist
License NumberNU200000233
License Number StateDC
# 2
Primary TaxonomyN
Taxonomy Code133NN1002X
TaxonomyNutrition Education Nutritionist
License NumberNU200000233
License Number StateDC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: