Healthcare Provider Details

I. General information

NPI: 1164147799
Provider Name (Legal Business Name): DEIDRE Y CANNON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/06/2022
Last Update Date: 10/06/2022
Certification Date: 10/02/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

31839 KINGSWOOD SQUARE
FARMINGTON HILLS MI
48334
US

IV. Provider business mailing address

6689 ORCHARD LAKE RD UNIT 142
WEST BLOOMFIELD MI
48322-3404
US

V. Phone/Fax

Practice location:
  • Phone: 248-836-7520
  • Fax:
Mailing address:
  • Phone: 248-836-7520
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246RP1900X
TaxonomyPhlebotomy Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: