Healthcare Provider Details

I. General information

NPI: 1326595703
Provider Name (Legal Business Name): GABRIEL CANNON R.D.N.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/02/2016
Last Update Date: 09/02/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

326 N MADISON AVE
BLANCHARD OK
73010-5929
US

IV. Provider business mailing address

326 N MADISON AVE
BLANCHARD OK
73010-5929
US

V. Phone/Fax

Practice location:
  • Phone: 405-413-7456
  • Fax:
Mailing address:
  • Phone: 405-413-7456
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133N00000X
TaxonomyNutritionist
License Number2126
License Number StateOK
# 2
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number2126
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: