Healthcare Provider Details

I. General information

NPI: 1427613090
Provider Name (Legal Business Name): LAURA EMILY GANNON MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/08/2019
Last Update Date: 09/11/2023
Certification Date: 06/30/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

871 RIDGEWAY LOOP RD STE 200
MEMPHIS TN
38120-4007
US

IV. Provider business mailing address

PO BOX 1000, DEPT 978
MEMPHIS TN
38148-0001
US

V. Phone/Fax

Practice location:
  • Phone: 901-821-9990
  • Fax: 901-821-9991
Mailing address:
  • Phone: 901-758-9900
  • Fax: 901-752-2335

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number65727
License Number StateTN
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: