Healthcare Provider Details

I. General information

NPI: 1457810855
Provider Name (Legal Business Name): MAUREEN STORMONT CANNON AU.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MAUREEN KEEGAN STORMONT

II. Dates (important events)

Enumeration Date: 03/15/2019
Last Update Date: 12/16/2025
Certification Date: 12/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

628 BIELENBERG DR
SAINT PAUL MN
55125-1401
US

IV. Provider business mailing address

4908 PINECROFT AVE N
STILLWATER MN
55082-5924
US

V. Phone/Fax

Practice location:
  • Phone: 612-874-1292
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code231H00000X
TaxonomyAudiologist
License Number10074
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: