Provider Demographics
NPI:1275614075
Name:CANNON, KATHLEEN A (GNP)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:A
Last Name:CANNON
Suffix:
Gender:F
Credentials:GNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:310 COUNTY ROAD 2
Mailing Address - Street 2:
Mailing Address - City:GREENE
Mailing Address - State:NY
Mailing Address - Zip Code:13778-2291
Mailing Address - Country:US
Mailing Address - Phone:607-656-4054
Mailing Address - Fax:
Practice Address - Street 1:179 N BROAD ST
Practice Address - Street 2:
Practice Address - City:NORWICH
Practice Address - State:NY
Practice Address - Zip Code:13815-1019
Practice Address - Country:US
Practice Address - Phone:607-337-4111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY358194363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYBB5837Medicare ID - Type Unspecified
NYS59410Medicare UPIN