Provider Demographics
NPI:1083195283
Name:DEBRA SUE CANNON
Entity Type:Organization
Organization Name:DEBRA SUE CANNON
Other - Org Name:CLARKSBURG FAMILY CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DEBRA
Authorized Official - Middle Name:SUE
Authorized Official - Last Name:CANNON
Authorized Official - Suffix:
Authorized Official - Credentials:APRN
Authorized Official - Phone:731-535-3636
Mailing Address - Street 1:2359 HIGHWAY 22 N
Mailing Address - Street 2:
Mailing Address - City:YUMA
Mailing Address - State:TN
Mailing Address - Zip Code:38390-4329
Mailing Address - Country:US
Mailing Address - Phone:731-553-5363
Mailing Address - Fax:731-535-3636
Practice Address - Street 1:2359 HIGHWAY 22 N
Practice Address - Street 2:
Practice Address - City:YUMA
Practice Address - State:TN
Practice Address - Zip Code:38390-4329
Practice Address - Country:US
Practice Address - Phone:731-535-3636
Practice Address - Fax:731-535-3636
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-08-24
Last Update Date:2019-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty