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General NPI Number Information
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NPI Number | 1184270209
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Entity Type | Individual
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Provider Name | KELLY CANNON APRN, FNP-BC
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Gender | Female
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Dates
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Enumeration Date | 08/14/2019
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Last Update Date | 10/23/2024
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Provider Practice Location Address
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Address Line | 1700 S 23RD ST
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City | FORT PIERCE
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State | FL
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Zip | 34950-4803
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Country | US
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Telephone | 772-461-4000
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Fax |
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Provider Business Mailing Address
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Address Line | 210 JUPITER LAKES BLVD STE 4105
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City | JUPITER
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State | FL
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Zip | 33458-7190
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Country | US
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Telephone | 561-743-9938
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Fax | 561-575-0801
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363L00000X
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Taxonomy Name | Nurse Practitioner
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License Number | APRN11005031
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License Number State | FL
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Taxonomy #2
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Taxonomy Code | 163WE0003X
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Taxonomy Name | Emergency Registered Nurse
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License Number | RN9312491
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License Number State | FL
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