Provider Demographics
NPI:1538286406
Name:CANNON, LORETTA (NURSE PRACTITIONER)
Entity Type:Individual
Prefix:MRS
First Name:LORETTA
Middle Name:
Last Name:CANNON
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 4811
Mailing Address - Street 2:
Mailing Address - City:INGLEWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90309-4811
Mailing Address - Country:US
Mailing Address - Phone:310-419-4845
Mailing Address - Fax:310-419-4845
Practice Address - Street 1:7226 S FIGUEROA ST
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90003-1721
Practice Address - Country:US
Practice Address - Phone:323-753-2401
Practice Address - Fax:323-750-5257
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA129460363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner