Healthcare Provider Details

I. General information

NPI: 1700110749
Provider Name (Legal Business Name): SHELLEY CANNON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/23/2009
Last Update Date: 05/30/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9201 N 5TH ST
PHOENIX AZ
85020-2532
US

IV. Provider business mailing address

9201 N 5TH ST
PHOENIX AZ
85020-2532
US

V. Phone/Fax

Practice location:
  • Phone: 602-331-5779
  • Fax: 602-331-7855
Mailing address:
  • Phone: 602-331-5779
  • Fax: 302-331-7855

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAP3189
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: