Healthcare Provider Details

I. General information

NPI: 1538174115
Provider Name (Legal Business Name): JODY LYNN CANNIFF RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/30/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

255 SMITH AVE N SUITE 100
SAINT PAUL MN
55102-2572
US

IV. Provider business mailing address

255 SMITH AVE N SUITE 100
SAINT PAUL MN
55102-2572
US

V. Phone/Fax

Practice location:
  • Phone: 651-726-2752
  • Fax: 651-310-1666
Mailing address:
  • Phone: 651-726-2752
  • Fax: 651-310-1666

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberR1328231
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: