Provider Demographics
NPI:1346525201
Name:CANNON, SPENCER (RN)
Entity Type:Individual
Prefix:
First Name:SPENCER
Middle Name:
Last Name:CANNON
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:161 S DOOLEY CT
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84102-4104
Mailing Address - Country:US
Mailing Address - Phone:801-696-8513
Mailing Address - Fax:
Practice Address - Street 1:161 S DOOLEY CT
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84102-4104
Practice Address - Country:US
Practice Address - Phone:801-696-8513
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-10-11
Last Update Date:2024-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT8038048-3102163W00000X, 163WP0200X
UT8038048-4405363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
No163W00000XNursing Service ProvidersRegistered Nurse
No163WP0200XNursing Service ProvidersRegistered NursePediatrics