Healthcare Provider Details

I. General information

NPI: 1255992202
Provider Name (Legal Business Name): LORENA CANNON APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/20/2019
Last Update Date: 03/08/2021
Certification Date: 01/15/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

893 E 9400 S
SANDY UT
84094-3671
US

IV. Provider business mailing address

893 E 9400 S
SANDY UT
84094-3671
US

V. Phone/Fax

Practice location:
  • Phone: 385-335-7862
  • Fax:
Mailing address:
  • Phone: 385-335-7862
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number11313685-4405
License Number StateUT
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number11313685-4405
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: