Healthcare Provider Details

I. General information

NPI: 1942611777
Provider Name (Legal Business Name): SUZANNE CANNON RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/14/2014
Last Update Date: 05/15/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

23 ONTARIO ST
HONEOYE FALLS NY
14472-1149
US

IV. Provider business mailing address

23 ONTARIO ST
HONEOYE FALLS NY
14472-1149
US

V. Phone/Fax

Practice location:
  • Phone: 585-624-2121
  • Fax: 585-624-7283
Mailing address:
  • Phone: 585-624-2121
  • Fax: 585-624-7283

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number3303891
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code163WD0400X
TaxonomyDiabetes Educator Registered Nurse
License Number21320216
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: