Provider Demographics
NPI:1144834730
Name:CANCEL, IVETTE
Entity type:Individual
Prefix:
First Name:IVETTE
Middle Name:
Last Name:CANCEL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4637 BURNSIDE DR
Mailing Address - Street 2:
Mailing Address - City:TOBYHANNA
Mailing Address - State:PA
Mailing Address - Zip Code:18466-3042
Mailing Address - Country:US
Mailing Address - Phone:347-623-4599
Mailing Address - Fax:
Practice Address - Street 1:1650 PARKVIEW AVE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10461-5221
Practice Address - Country:US
Practice Address - Phone:347-623-4599
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-01
Last Update Date:2020-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY023606225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist