MEDICARE: DILYARA CANNON

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	AP7479	AZ
2	363L00000X	Nurse Practitioner	AP7479	AZ

General Provider Information

NPI Number	:	1114325784
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DILYARA CANNON

Provider Business Mailing Address
First Line	:	5653 S HIGHWAY 95
Second Line	:	STE A
City	:	FORT MOHAVE
State	:	AZ
Zip	:	86426-6068
Country	:	US
Telephone Number	:	928-768-2558
Fax Number	:	928-768-2874

Provider Business Practice Location Address
First Line	:	5653 S HIGHWAY 95
Second Line	:	STE A
City	:	FORT MOHAVE
State	:	AZ
Zip	:	86426-6068
Country	:	US
Telephone Number	:	928-768-2558
Fax Number	:	928-768-2874

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/15/2014
Last Update Date	:	03/04/2025

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Directions to “ DILYARA CANNON ” Practice Location

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