Healthcare Provider Details

I. General information

NPI: 1104735984
Provider Name (Legal Business Name): CANON WHEATLEY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/05/2026
Last Update Date: 09/05/2026
Certification Date: 09/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2652 LAKE AUSTIN BLVD
AUSTIN TX
78703-4429
US

IV. Provider business mailing address

2652 LAKE AUSTIN BLVD
AUSTIN TX
78703-4429
US

V. Phone/Fax

Practice location:
  • Phone: 512-474-2001
  • Fax: 737-610-6383
Mailing address:
  • Phone: 512-747-2001
  • Fax: 737-610-6383

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183700000X
TaxonomyPharmacy Technician
License Number46288
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: