Provider Demographics
NPI:1336469931
Name:CANNON, CARA MARJORIE ANNE
Entity Type:Individual
Prefix:
First Name:CARA
Middle Name:MARJORIE ANNE
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 1:2274 CHESTERFIELD CIR
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33813-5837
Mailing Address - Country:US
Mailing Address - Phone:863-688-3550
Mailing Address - Fax:
Practice Address - Street 1:5950 SOUTH FLORIDA AVE.
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33813-2532
Practice Address - Country:US
Practice Address - Phone:863-688-3550
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-04
Last Update Date:2015-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC164586390200000X
FLME124168208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program