Provider Demographics
NPI:1417601709
Name:CANNON, MELISSA THICK (APRN FNP-C)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:THICK
Last Name:CANNON
Suffix:
Gender:F
Credentials:APRN FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9667 BLACK JACK RD
Mailing Address - Street 2:
Mailing Address - City:MACCLENNY
Mailing Address - State:FL
Mailing Address - Zip Code:32063-4517
Mailing Address - Country:US
Mailing Address - Phone:904-887-9340
Mailing Address - Fax:
Practice Address - Street 1:542325 US HIGHWAY 1
Practice Address - Street 2:
Practice Address - City:CALLAHAN
Practice Address - State:FL
Practice Address - Zip Code:32011-6496
Practice Address - Country:US
Practice Address - Phone:904-879-4233
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-07
Last Update Date:2022-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11017973363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily