Healthcare Provider Details

I. General information

NPI: 1487688081
Provider Name (Legal Business Name): EMILY CANNON GILGEN RD, CDE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: EMILY A CANNON RD CD

II. Dates (important events)

Enumeration Date: 07/10/2006
Last Update Date: 10/24/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 E 3900 S NMOB 3300
SALT LAKE CITY UT
84124-1300
US

IV. Provider business mailing address

1200 E 3900 S NMOB 3300
SALT LAKE CITY UT
84124-1300
US

V. Phone/Fax

Practice location:
  • Phone: 801-268-7931
  • Fax: 801-270-3318
Mailing address:
  • Phone: 801-268-7931
  • Fax: 801-270-3318

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number952619
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code133VN1006X
TaxonomyMetabolic Nutrition Registered Dietitian
License Number6725542-4901
License Number StateUT
# 3
Primary TaxonomyN
Taxonomy Code174H00000X
TaxonomyHealth Educator
License Number20810055
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: