Healthcare Provider Details

I. General information

NPI: 1568417376
Provider Name (Legal Business Name): LAURA J CANNON APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/23/2006
Last Update Date: 11/11/2021
Certification Date: 11/11/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1950 CIRCLE OF HOPE CLINIC 1A
SALT LAKE CITY UT
84112-5550
US

IV. Provider business mailing address

127 SO. 500 EAST #600
SALT LAKE CITY UT
84102-1971
US

V. Phone/Fax

Practice location:
  • Phone: 801-585-0100
  • Fax: 801-585-7902
Mailing address:
  • Phone: 801-587-6705
  • Fax: 801-715-8228

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number269735-4405
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code363LC0200X
TaxonomyCritical Care Medicine Nurse Practitioner
License Number269735-4405
License Number StateUT
# 3
Primary TaxonomyN
Taxonomy Code163WX0800X
TaxonomyOrthopedic Registered Nurse
License Number269735-4405
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: