MEDICARE: KRISTAL M CANNICI FNP-BC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	26NJ15396200	NJ

General Provider Information

NPI Number	:	1174490122
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KRISTAL M CANNICI FNP-BC

Provider Business Mailing Address
First Line	:	PO BOX 95000, LB#7550
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19195-7550
Country	:	US
Telephone Number	:	844-362-1735
Fax Number	:

Provider Business Practice Location Address
First Line	:	375 E MCFARLAN ST STE 2
Second Line	:
City	:	DOVER
State	:	NJ
Zip	:	07801-3628
Country	:	US
Telephone Number	:	973-366-5859
Fax Number	:	973-366-0026

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/22/2025
Last Update Date	:	05/05/2026

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