Healthcare Provider Details

I. General information

NPI: 1548123060
Provider Name (Legal Business Name): JACQUELINE HINES CANNADY LAB OWNER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/03/2025
Last Update Date: 12/03/2025
Certification Date: 11/20/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

151 MCCORMICK RD
SANFORD NC
27332
US

IV. Provider business mailing address

151 MC CORMICK ROAD
SANFORD NC
27332
US

V. Phone/Fax

Practice location:
  • Phone: 919-592-7374
  • Fax:
Mailing address:
  • Phone: 919-592-7374
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: