Provider Demographics
NPI:1518994672
Name:CANNON, COLLEEN G (CFNP)
Entity Type:Individual
Prefix:MRS
First Name:COLLEEN
Middle Name:G
Last Name:CANNON
Suffix:
Gender:F
Credentials:CFNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2500 N STATE ST
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39216-4500
Mailing Address - Country:US
Mailing Address - Phone:601-984-5560
Mailing Address - Fax:601-984-5565
Practice Address - Street 1:2500 N STATE ST
Practice Address - Street 2:DIVISION OF INFECTIOUS DISEASE
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216-4500
Practice Address - Country:US
Practice Address - Phone:601-984-5560
Practice Address - Fax:601-984-5565
Is Sole Proprietor?:No
Enumeration Date:2006-06-26
Last Update Date:2014-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR850953363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MSP01233199OtherRAILROAD MEDICARE
MS08153779Medicaid
MSP00815217OtherRAILROAD MEDICARE ID
MSR850953OtherNURSING LICENSE NUMBER
MSR850953OtherNURSING LICENSE NUMBER
MS512G7003Medicare UPIN
MS500001350Medicare PIN
MSP01233199OtherRAILROAD MEDICARE