Healthcare Provider Details

I. General information

NPI: 1790737294
Provider Name (Legal Business Name): STEPHEN JEROME CANNON CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/16/2006
Last Update Date: 05/03/2023
Certification Date: 05/03/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4810 N DAVIS HWY
PENSACOLA FL
32503-2341
US

IV. Provider business mailing address

4828 N DAVIS HWY
PENSACOLA FL
32503-2341
US

V. Phone/Fax

Practice location:
  • Phone: 850-474-8988
  • Fax: 850-476-5312
Mailing address:
  • Phone: 850-477-8109
  • Fax: 850-478-2412

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number28237950A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberAP115468
License Number StateTX
# 3
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberARNP9205700
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: