Provider Demographics
NPI:1043909765
Name:CANNON, CHRISTINA R
Entity Type:Individual
Prefix:
First Name:CHRISTINA
Middle Name:R
Last Name:CANNON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5755 MARIGOLD LOOP
Mailing Address - Street 2:
Mailing Address - City:CRESTVIEW
Mailing Address - State:FL
Mailing Address - Zip Code:32539-8406
Mailing Address - Country:US
Mailing Address - Phone:803-686-0411
Mailing Address - Fax:
Practice Address - Street 1:130 LETOURNEAU AVE. BLDG. 90311
Practice Address - Street 2:
Practice Address - City:HURLBURT FIELD
Practice Address - State:FL
Practice Address - Zip Code:32544
Practice Address - Country:US
Practice Address - Phone:850-881-5061
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-08
Last Update Date:2023-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW209851041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical