=====================================================
General NPI Number Information
=====================================================
NPI Number | 1689080384
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | VERONICA LEA CANNON APRN
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/02/2014
-----------------------------------------------------
Last Update Date | 02/29/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1604 MLK BLVD
-----------------------------------------------------
City | MALVERN
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72104
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 501-732-5400
-----------------------------------------------------
Fax | 501-325-9650
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1604 MLK BLVD
-----------------------------------------------------
City | MALVERN
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72104
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 501-732-5400
-----------------------------------------------------
Fax | 501-325-9650
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | A004099
-----------------------------------------------------
License Number State | AR
-----------------------------------------------------