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General NPI Number Information
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NPI Number | 1760968804
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Entity Type | Individual
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Provider Name | AMANDA GRAVES CANNON FNP
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Gender | Female
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Dates
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Enumeration Date | 07/12/2018
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Last Update Date | 11/15/2024
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Provider Practice Location Address
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Address Line | 667 E 500 N STE 200
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City | VINEYARD
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State | UT
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Zip | 84059-6004
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Country | US
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Telephone | 801-669-5758
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Fax | 801-216-8357
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Provider Business Mailing Address
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Address Line | 667 E 500 N STE 200
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City | VINEYARD
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State | UT
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Zip | 84059-6004
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Country | US
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Telephone | 801-669-5758
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Fax | 801-216-8357
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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 | 363LX0001X
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Taxonomy Name | Obstetrics & Gynecology Nurse Practitioner
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License Number | 911041
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License Number State | UT
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Taxonomy #2
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Taxonomy Code | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number | 9111041-4405
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License Number State | UT
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