=====================================================
General NPI Number Information
=====================================================
NPI Number | 1124645007
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JOHN WILLIAM CANN MSN, FNP-BC, APRN
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/26/2020
-----------------------------------------------------
Last Update Date | 06/29/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 655 BROADWAY
-----------------------------------------------------
City | REVERE
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 02151-2347
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 617-285-8731
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 111 DERBY RD
-----------------------------------------------------
City | REVERE
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 02151-1803
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 617-285-8731
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 163WS0121X
-----------------------------------------------------
Taxonomy Name | Plastic Surgery Registered Nurse
-----------------------------------------------------
License Number | RN2298986
-----------------------------------------------------
License Number State | MA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 174H00000X
-----------------------------------------------------
Taxonomy Name | Health Educator
-----------------------------------------------------
License Number | RN2298986
-----------------------------------------------------
License Number State | MA
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 363LA2100X
-----------------------------------------------------
Taxonomy Name | Acute Care Nurse Practitioner
-----------------------------------------------------
License Number | RN2298986
-----------------------------------------------------
License Number State | MA
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | RN2298986
-----------------------------------------------------
License Number State | MA
-----------------------------------------------------