Basic Information
Provider Information
NPI: 1003004540
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: CABANELLAS
FirstName: JENNINE
MiddleName: MARIE
NamePrefix: DR.
NameSuffix:  
Credential: MD
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 2889 10TH AVE N
Address2: SUITE 306
City: PALM SPRINGS
State: FL
PostalCode: 334613045
CountryCode: US
TelephoneNumber: 5612273101
FaxNumber: 5612273182
Practice Location
Address1: 2889 10TH AVE N
Address2: SUITE 306
City: PALM SPRINGS
State: FL
PostalCode: 334613045
CountryCode: US
TelephoneNumber: 5612273101
FaxNumber: 5612273182
Other Information
ProviderEnumerationDate: 10/10/2007
LastUpdateDate: 03/10/2016
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: Y
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
174400000XME83781FLN Other Service ProvidersSpecialist 
207W00000XME83781FLY Allopathic & Osteopathic PhysiciansOphthalmology 

ID Information
IDTypeStateIssuerDescription
26798330005FL MEDICAID


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