Healthcare Provider Details

I. General information

NPI: 1841233434
Provider Name (Legal Business Name): AILEEN CAROL CANNON M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/13/2006
Last Update Date: 01/04/2024
Certification Date: 01/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4202 E FOWLER AVE SHS 100
TAMPA FL
33620-6750
US

IV. Provider business mailing address

PO BOX 917770
ORLANDO FL
32891-0001
US

V. Phone/Fax

Practice location:
  • Phone: 813-974-2331
  • Fax:
Mailing address:
  • Phone: 813-974-2201
  • Fax: 813-974-2812

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberME114340
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: