Healthcare Provider Details

I. General information

NPI: 1497527774
Provider Name (Legal Business Name): JENNIFER LYNN CANO RN, BSN,IBCLC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/30/2023
Last Update Date: 10/30/2023
Certification Date: 10/30/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1285 HEMBREE RD STE 100
ROSWELL GA
30076-5715
US

IV. Provider business mailing address

5088 BRIDGEPORT WAY
PEACHTREE CORNERS GA
30092-1713
US

V. Phone/Fax

Practice location:
  • Phone: 404-449-5595
  • Fax:
Mailing address:
  • Phone: 678-612-9730
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WL0100X
TaxonomyLactation Consultant (Registered Nurse)
License NumberRN160828
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: