Provider Demographics
NPI:1437574068
Name:CANNON, TAMMY MAE LYNN
Entity Type:Individual
Prefix:MRS
First Name:TAMMY
Middle Name:MAE 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 1:11279 HARVEY PETTIT RD
Mailing Address - Street 2:
Mailing Address - City:LE GRAND
Mailing Address - State:CA
Mailing Address - Zip Code:95333-9712
Mailing Address - Country:US
Mailing Address - Phone:559-455-3375
Mailing Address - Fax:
Practice Address - Street 1:1904 RICHLAND AVE
Practice Address - Street 2:SUITE A
Practice Address - City:CERES
Practice Address - State:CA
Practice Address - Zip Code:95307-4562
Practice Address - Country:US
Practice Address - Phone:209-300-8800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-02-18
Last Update Date:2014-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAVN 210501164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse