MEDICARE: MARY GRACE CANNON RN

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	163W00000X	Registered Nurse	1081173	TX

General Provider Information

NPI Number	:	1184552705
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARY GRACE CANNON RN

Provider Business Mailing Address
First Line	:	2420 TARRYTOWN MALL
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77057-4514
Country	:	US
Telephone Number	:	832-918-2159
Fax Number	:

Provider Business Practice Location Address
First Line	:	2420 TARRYTOWN MALL
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77057-4514
Country	:	US
Telephone Number	:	832-918-2159
Fax Number	:

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

Provider Enumeration Date	:	05/12/2026
Last Update Date	:	05/12/2026

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