Provider Demographics
NPI:1861160459
Name:CANALETICH, ABIGAIL L
Entity type:Individual
Prefix:
First Name:ABIGAIL
Middle Name:L
Last Name:CANALETICH
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 1:9 MIKE LN
Mailing Address - Street 2:
Mailing Address - City:SMITHTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:11787-2326
Mailing Address - Country:US
Mailing Address - Phone:631-561-5533
Mailing Address - Fax:
Practice Address - Street 1:9 MIKE LN
Practice Address - Street 2:
Practice Address - City:SMITHTOWN
Practice Address - State:NY
Practice Address - Zip Code:11787-2326
Practice Address - Country:US
Practice Address - Phone:631-561-5533
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-31
Last Update Date:2022-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
NY390200000X
NY02791101363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program