Provider Demographics
NPI:1235634221
Name:CANNON, LAURA D (FNP-C)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:D
Last Name:CANNON
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6375 U S HWY 6
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:IN
Mailing Address - Zip Code:46368-5218
Mailing Address - Country:US
Mailing Address - Phone:219-762-3196
Mailing Address - Fax:219-763-6438
Practice Address - Street 1:6375 U S HWY 6
Practice Address - Street 2:
Practice Address - City:PORTAGE
Practice Address - State:IN
Practice Address - Zip Code:46368-5218
Practice Address - Country:US
Practice Address - Phone:219-762-3196
Practice Address - Fax:219-763-6438
Is Sole Proprietor?:No
Enumeration Date:2018-03-29
Last Update Date:2021-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71007892A363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care