Healthcare Provider Details

I. General information

NPI: 1154579977
Provider Name (Legal Business Name): CARRIE ELLA CANNON M.A.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: KARI ELLA HUGHES M.A.

II. Dates (important events)

Enumeration Date: 09/04/2008
Last Update Date: 09/30/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1615 MARTIN LUTHER KING BLVD
MALVERN AR
72104-2233
US

IV. Provider business mailing address

571 SAGINAW EDDY RD
DONALDSON AR
71941-8060
US

V. Phone/Fax

Practice location:
  • Phone: 501-332-5236
  • Fax:
Mailing address:
  • Phone: 501-515-8656
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number3455-C
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: