Provider Demographics
NPI:1114325784
Name:CANNON, DILYARA
Entity Type:Individual
Prefix:
First Name:DILYARA
Middle Name:
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 1:5653 S HIGHWAY 95
Mailing Address - Street 2:STE A
Mailing Address - City:FORT MOHAVE
Mailing Address - State:AZ
Mailing Address - Zip Code:86426-6068
Mailing Address - Country:US
Mailing Address - Phone:928-768-2558
Mailing Address - Fax:928-768-2874
Practice Address - Street 1:5653 S HIGHWAY 95
Practice Address - Street 2:STE A
Practice Address - City:FORT MOHAVE
Practice Address - State:AZ
Practice Address - Zip Code:86426-6068
Practice Address - Country:US
Practice Address - Phone:928-768-2558
Practice Address - Fax:928-768-2874
Is Sole Proprietor?:No
Enumeration Date:2014-12-15
Last Update Date:2014-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAP7479363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily