MEDICARE: SUSIE SHANTILA CANNON TRADITIONAL MIDWIFE

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	175M00000X	Lay Midwife	NA	MS

General Provider Information

NPI Number	:	1487508024
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SUSIE SHANTILA CANNON TRADITIONAL MIDWIFE

Provider Business Mailing Address
First Line	:	184 LEWELLEN ST
Second Line	:
City	:	WEST POINT
State	:	MS
Zip	:	39773-2138
Country	:	US
Telephone Number	:	504-533-4716
Fax Number	:

Provider Business Practice Location Address
First Line	:	1800 W MAIN ST
Second Line	:
City	:	TUPELO
State	:	MS
Zip	:	38801-3254
Country	:	US
Telephone Number	:	504-533-4716
Fax Number	:

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

Provider Enumeration Date	:	02/23/2026
Last Update Date	:	02/23/2026

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