Healthcare Provider Details

I. General information

NPI: 1376019851
Provider Name (Legal Business Name): ALEXIS HELEN CANNON NBC-HWC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/22/2018
Last Update Date: 09/18/2024
Certification Date: 09/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

67-236 KUKEA CIR
WAIALUA HI
96791-9517
US

IV. Provider business mailing address

67-236 KUKEA CIR
WAIALUA HI
96791-9517
US

V. Phone/Fax

Practice location:
  • Phone: 843-655-2641
  • Fax:
Mailing address:
  • Phone: 843-655-2641
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-18-68725
License Number StateHI
# 2
Primary TaxonomyY
Taxonomy Code171400000X
TaxonomyHealth & Wellness Coach
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: