Healthcare Provider Details

I. General information

NPI: 1427983337
Provider Name (Legal Business Name): SAMIYA CANNON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/15/2026
Last Update Date: 06/15/2026
Certification Date: 06/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10916 EDUCATION WAY APT 1305A
CHARLOTTE NC
28262-7125
US

IV. Provider business mailing address

10114 PINTAIL PL APT 1305
CHARLOTTE NC
28269-1930
US

V. Phone/Fax

Practice location:
  • Phone: 919-987-4524
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-25-459994
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: