Healthcare Provider Details

I. General information

NPI: 1386551430
Provider Name (Legal Business Name): AUDREA CANNON LMT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/25/2026
Last Update Date: 08/25/2026
Certification Date: 08/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3033 OGDEN AVE STE 302
LISLE IL
60532-1976
US

IV. Provider business mailing address

424 S WARREN AVE
PALATINE IL
60074-6408
US

V. Phone/Fax

Practice location:
  • Phone: 847-571-5455
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number227034833
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: