Provider Demographics
NPI:1386015345
Name:CANNON, GINA
Entity Type:Individual
Prefix:
First Name:GINA
Middle Name:
Last Name:CANNON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:GINA
Other - Middle Name:BUONO
Other - Last Name:CANNON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LPN
Mailing Address - Street 1:1517 DURHAM RD
Mailing Address - Street 2:
Mailing Address - City:PENNDEL
Mailing Address - State:PA
Mailing Address - Zip Code:19047-5707
Mailing Address - Country:US
Mailing Address - Phone:215-752-1541
Mailing Address - Fax:215-752-7195
Practice Address - Street 1:1517 DURHAM RD
Practice Address - Street 2:
Practice Address - City:PENNDEL
Practice Address - State:PA
Practice Address - Zip Code:19047-5707
Practice Address - Country:US
Practice Address - Phone:215-752-1541
Practice Address - Fax:215-752-7195
Is Sole Proprietor?:No
Enumeration Date:2015-10-15
Last Update Date:2015-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPN264410164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse