MEDICARE: MRS. JENNIFER CANNON APRN

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	363L00000X	Nurse Practitioner	5902	CT
2	363LF0000X	Family Nurse Practitioner	005902	CT
3	363LF0000X	Family Nurse Practitioner	5902	CT

General Provider Information

NPI Number	:	1528461647
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. JENNIFER CANNON APRN

Provider Business Mailing Address
First Line	:	166 ALBANY TPKE STE 7
Second Line	:
City	:	CANTON
State	:	CT
Zip	:	06019-2546
Country	:	US
Telephone Number	:	860-935-6680
Fax Number	:

Provider Business Practice Location Address
First Line	:	166 ALBANY TPKE STE 7
Second Line	:
City	:	CANTON
State	:	CT
Zip	:	06019-2546
Country	:	US
Telephone Number	:	860-935-6680
Fax Number	:

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

Provider Enumeration Date	:	10/02/2014
Last Update Date	:	04/18/2023

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