Provider Demographics
NPI:1538316138
Name:CANNON, CONSUELO NORWOOD (RN)
Entity Type:Individual
Prefix:
First Name:CONSUELO
Middle Name:NORWOOD
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 1:50 W WHITE ST
Mailing Address - Street 2:
Mailing Address - City:BRENTWOOD
Mailing Address - State:NY
Mailing Address - Zip Code:11717-1310
Mailing Address - Country:US
Mailing Address - Phone:631-434-2439
Mailing Address - Fax:
Practice Address - Street 1:50 W WHITE ST
Practice Address - Street 2:
Practice Address - City:BRENTWOOD
Practice Address - State:NY
Practice Address - Zip Code:11717-1310
Practice Address - Country:US
Practice Address - Phone:631-434-2439
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-26
Last Update Date:2012-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY436036-1163WH0200X, 163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No163WH0200XNursing Service ProvidersRegistered NurseHome Health