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General NPI Number Information
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NPI Number | 1790396703
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Entity Type | Individual
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Provider Name | JERMAINE CANNON LMT
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Gender | Male
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Dates
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Enumeration Date | 08/13/2020
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Last Update Date | 08/13/2020
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Provider Practice Location Address
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Address Line | 1 MURPHY RD
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City | WILMINGTON
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State | DE
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Zip | 19803-3044
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Country | US
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Telephone | 302-543-4004
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Fax |
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Provider Business Mailing Address
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Address Line | 24 NICOLE CT
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City | NEW CASTLE
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State | DE
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Zip | 19720-3762
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Country | US
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Telephone | 302-377-5838
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Fax |
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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 | 174400000X
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Taxonomy Name | Specialist
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License Number | MT-0003237
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License Number State | DE
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