Provider Demographics
NPI:1144598723
Name:CANNON, TAMMY GALLAGHER (FNP)
Entity Type:Individual
Prefix:
First Name:TAMMY
Middle Name:GALLAGHER
Last Name:CANNON
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:TAMMY
Other - Middle Name:L
Other - Last Name:GALLAGHER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 33932
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71130-3932
Mailing Address - Country:US
Mailing Address - Phone:318-675-5161
Mailing Address - Fax:
Practice Address - Street 1:1501 KINGS HWY
Practice Address - Street 2:DEPARTMENT OF NEUROSURGERY
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71103-4228
Practice Address - Country:US
Practice Address - Phone:318-675-5161
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-12-09
Last Update Date:2011-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LARN100005-AP06307363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner