Healthcare Provider Details

I. General information

NPI: 1619761921
Provider Name (Legal Business Name): GEORGE CANNON APRN, PMHNP-BC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/09/2025
Last Update Date: 09/21/2026
Certification Date: 09/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 S MAIN AVE UNIT 100
MINNEOLA FL
34715-9578
US

IV. Provider business mailing address

PO BOX 203
MINNEOLA FL
34755-0203
US

V. Phone/Fax

Practice location:
  • Phone: 352-703-6341
  • Fax: 352-743-1153
Mailing address:
  • Phone: 352-703-6341
  • Fax: 352-743-1153

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number11038763
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: