Healthcare Provider Details

I. General information

NPI: 1992633804
Provider Name (Legal Business Name): MAKHIAH CANNON PEAK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/11/2026
Last Update Date: 05/11/2026
Certification Date: 05/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21 W CLARKE AVE STE 1050
MILFORD DE
19963-1857
US

IV. Provider business mailing address

646 COLDWATER DR
CLAYTON DE
19938-3906
US

V. Phone/Fax

Practice location:
  • Phone: 302-503-7650
  • Fax:
Mailing address:
  • Phone: 302-244-2960
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateDE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: