Provider Demographics
NPI:1497509038
Name:CANNON, LAURA FAYE (MS, RDN)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:FAYE
Last Name:CANNON
Suffix:
Gender:F
Credentials:MS, RDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1931 GLENDON AVE APT 101
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90025-4603
Mailing Address - Country:US
Mailing Address - Phone:310-904-3700
Mailing Address - Fax:
Practice Address - Street 1:1931 GLENDON AVE APT 101
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90025-4603
Practice Address - Country:US
Practice Address - Phone:310-904-3700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-04-11
Last Update Date:2024-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA86276215133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered