Healthcare Provider Details

I. General information

NPI: 1962047993
Provider Name (Legal Business Name): DYONNA CANNON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/13/2019
Last Update Date: 11/13/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7125 GRAND MONTECITO PKWY STE 130
LAS VEGAS NV
89149-0261
US

IV. Provider business mailing address

3300 N TENAYA WAY APT 2109
LAS VEGAS NV
89129-6252
US

V. Phone/Fax

Practice location:
  • Phone: 702-396-0101
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: