Provider Demographics
NPI:1467109223
Name:CANNON, TIKARA SHAUNEICE (CBS, MILC)
Entity Type:Individual
Prefix:
First Name:TIKARA
Middle Name:SHAUNEICE
Last Name:CANNON
Suffix:
Gender:F
Credentials:CBS, MILC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:162 RICHARDS CT
Mailing Address - Street 2:
Mailing Address - City:RUCKERSVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:22968-3709
Mailing Address - Country:US
Mailing Address - Phone:434-218-0593
Mailing Address - Fax:
Practice Address - Street 1:162 RICHARDS CT
Practice Address - Street 2:
Practice Address - City:RUCKERSVILLE
Practice Address - State:VA
Practice Address - Zip Code:22968-3709
Practice Address - Country:US
Practice Address - Phone:434-218-0593
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-02
Last Update Date:2022-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
374J00000X
VA174N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174N00000XOther Service ProvidersLactation Consultant, Non-RN
No374J00000XNursing Service Related ProvidersDoula