MEDICARE: MONICA VONCANNON 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	629782	TX

General Provider Information

NPI Number	:	1417136953
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MONICA VONCANNON RN

Provider Business Mailing Address
First Line	:	301 UNIVERSITY BLVD
Second Line	:	PROVIDER ENROLLMENT -- RT. 1022
City	:	GALVESTON
State	:	TX
Zip	:	77555-5302
Country	:	US
Telephone Number	:	409-747-0890
Fax Number	:	409-747-1023

Provider Business Practice Location Address
First Line	:	3828 HUGHES CT
Second Line	:	STE 104
City	:	DICKINSON
State	:	TX
Zip	:	77539-6244
Country	:	US
Telephone Number	:	281-534-2576
Fax Number	:

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

Provider Enumeration Date	:	11/01/2007
Last Update Date	:	11/01/2007

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