Provider Demographics
NPI:1043803125
Name:CANON, REBECCA SUZANNE ISABELLE (ARNP)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:SUZANNE ISABELLE
Last Name:CANON
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4951 GRANDE DR
Mailing Address - Street 2:
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32504-8965
Mailing Address - Country:US
Mailing Address - Phone:850-473-0100
Mailing Address - Fax:850-473-0500
Practice Address - Street 1:4951 GRANDE DR
Practice Address - Street 2:
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32504-8965
Practice Address - Country:US
Practice Address - Phone:850-473-0100
Practice Address - Fax:850-473-0500
Is Sole Proprietor?:No
Enumeration Date:2021-02-18
Last Update Date:2022-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN11011563363L00000X, 363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL109796100Medicaid