Provider Demographics
NPI:1033843859
Name:CANON, KAILEEN RILEY (FNP-C)
Entity Type:Individual
Prefix:
First Name:KAILEEN
Middle Name:RILEY
Last Name:CANON
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:66 MOUNTAIN ST
Mailing Address - Street 2:
Mailing Address - City:HAYDENVILLE
Mailing Address - State:MA
Mailing Address - Zip Code:01039-9723
Mailing Address - Country:US
Mailing Address - Phone:413-588-8786
Mailing Address - Fax:
Practice Address - Street 1:234 RUSSELL ST # 7
Practice Address - Street 2:
Practice Address - City:HADLEY
Practice Address - State:MA
Practice Address - Zip Code:01035-3534
Practice Address - Country:US
Practice Address - Phone:413-586-6020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-16
Last Update Date:2022-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAF07221086363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care