Healthcare Provider Details

I. General information

NPI: 1215872965
Provider Name (Legal Business Name): ABIGAIL CANNON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: ABIGAIL CLOUSE

II. Dates (important events)

Enumeration Date: 04/21/2026
Last Update Date: 04/21/2026
Certification Date: 04/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1760 E KEN PRATT BLVD STE 201
LONGMONT CO
80504-5311
US

IV. Provider business mailing address

1963 WINDING DR
LONGMONT CO
80504-2415
US

V. Phone/Fax

Practice location:
  • Phone: 720-718-8222
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License NumberAPN.1001381-NP
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: