Healthcare Provider Details

I. General information

NPI: 1497079081
Provider Name (Legal Business Name): SHERIDAN CANNONLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/25/2010
Last Update Date: 03/25/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 WARREN AVE
HO HO KUS NJ
07423-1566
US

IV. Provider business mailing address

PO BOX 158
WYCKOFF NJ
07481-0158
US

V. Phone/Fax

Practice location:
  • Phone: 201-251-2525
  • Fax: 201-251-8488
Mailing address:
  • Phone: 201-251-2525
  • Fax: 201-251-8488

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License NumberMA69017
License Number StateNJ

VIII. Authorized Official

Name: DR. LISA MARIE CANNON
Title or Position: PHYSICIAN
Credential: M.D
Phone: 201-251-2525