Healthcare Provider Details

I. General information

NPI: 1538316138
Provider Name (Legal Business Name): CONSUELO NORWOOD CANNON R.N.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/26/2008
Last Update Date: 01/05/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

50 W WHITE ST
BRENTWOOD NY
11717-1310
US

IV. Provider business mailing address

50 W WHITE ST
BRENTWOOD NY
11717-1310
US

V. Phone/Fax

Practice location:
  • Phone: 631-434-2439
  • Fax:
Mailing address:
  • Phone: 631-434-2439
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WH0200X
TaxonomyHome Health Registered Nurse
License Number436036-1
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number436036-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: