Provider Demographics
NPI:1396388328
Name:CANNON, CANDACE LYNN
Entity Type:Individual
Prefix:
First Name:CANDACE
Middle Name:LYNN
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 1:3315 CLEMONS RD
Mailing Address - Street 2:
Mailing Address - City:PLANT CITY
Mailing Address - State:FL
Mailing Address - Zip Code:33566-4647
Mailing Address - Country:US
Mailing Address - Phone:813-625-3143
Mailing Address - Fax:
Practice Address - Street 1:3315 CLEMONS RD
Practice Address - Street 2:
Practice Address - City:PLANT CITY
Practice Address - State:FL
Practice Address - Zip Code:33566-4647
Practice Address - Country:US
Practice Address - Phone:813-625-3143
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-22
Last Update Date:2019-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist