=====================================================
General NPI Number Information
=====================================================
NPI Number | 1982527131
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MICKEY ALAN CANNON
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/04/2026
-----------------------------------------------------
Last Update Date | 08/04/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1010 W MONROE ST APT 4H
-----------------------------------------------------
City | GRENADA
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 38901-5031
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 662-983-0487
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1010 W MONROE ST APT 4H
-----------------------------------------------------
City | GRENADA
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 38901-5031
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
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 | 908516
-----------------------------------------------------
License Number State | MS
-----------------------------------------------------