MEDICARE: VICTORIA LEE CANNON RN

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	163WG0000X	General Practice Registered Nurse	320986	OH
2	163WH0200X	Home Health Registered Nurse	320986	OH
3	163WM0705X	Medical-Surgical Registered Nurse	320986	OH

General Provider Information

NPI Number	:	1043593312
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	VICTORIA LEE CANNON RN

Provider Business Mailing Address
First Line	:	449 EAST TUSCARAWAS AVE.
Second Line	:	PO BOX 735
City	:	GNADENHUTTEN
State	:	OH
Zip	:	44629-0735
Country	:	US
Telephone Number	:	330-827-7921
Fax Number	:

Provider Business Practice Location Address
First Line	:	449 EAST TUSCARAWAS AVE.
Second Line	:
City	:	GNADENHUTTEN
State	:	OH
Zip	:	44629-0735
Country	:	US
Telephone Number	:	330-827-7921
Fax Number	:

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

Provider Enumeration Date	:	09/23/2011
Last Update Date	:	09/23/2011

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