Provider Demographics
NPI:1407375207
Name:CANNON, KIMBERLY LYNN (FNP-BC)
Entity Type:Individual
Prefix:MS
First Name:KIMBERLY
Middle Name:LYNN
Last Name:CANNON
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5039 PAGE AVE
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MI
Mailing Address - Zip Code:49201-9101
Mailing Address - Country:US
Mailing Address - Phone:313-713-4543
Mailing Address - Fax:
Practice Address - Street 1:3857 COOPER ST
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MI
Practice Address - Zip Code:49201-7547
Practice Address - Country:US
Practice Address - Phone:517-780-5600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-12
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704304007363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily