Healthcare Provider Details

I. General information

NPI: 1417431263
Provider Name (Legal Business Name): SHANNON CANNON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/18/2018
Last Update Date: 01/22/2025
Certification Date: 01/22/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 YEARSLEY MILL RD
MEDIA PA
19063-5593
US

IV. Provider business mailing address

812R CRUM CREEK RD
SPRINGFIELD PA
19064-1037
US

V. Phone/Fax

Practice location:
  • Phone: 888-227-3898
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberSPO30927
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN627631
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: