Provider Demographics
NPI:1497027197
Name:CANNON, STACEY L (RN)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:L
Last Name:CANNON
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5454 E STATE ST
Mailing Address - Street 2:
Mailing Address - City:HERMITAGE
Mailing Address - State:PA
Mailing Address - Zip Code:16148-9441
Mailing Address - Country:US
Mailing Address - Phone:724-346-2123
Mailing Address - Fax:724-346-0366
Practice Address - Street 1:5454 E STATE ST
Practice Address - Street 2:
Practice Address - City:HERMITAGE
Practice Address - State:PA
Practice Address - Zip Code:16148-9441
Practice Address - Country:US
Practice Address - Phone:724-346-2123
Practice Address - Fax:724-346-0366
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-27
Last Update Date:2012-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARN502451L163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse