Provider Demographics
NPI:1558316315
Name:LISA CANNON MD FCCP
Entity Type:Organization
Organization Name:LISA CANNON MD FCCP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:LISA
Authorized Official - Middle Name:M
Authorized Official - Last Name:CANNON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:201-251-2525
Mailing Address - Street 1:PO BOX 158
Mailing Address - Street 2:
Mailing Address - City:WYCKOFF
Mailing Address - State:NJ
Mailing Address - Zip Code:07481-0158
Mailing Address - Country:US
Mailing Address - Phone:201-251-2525
Mailing Address - Fax:
Practice Address - Street 1:110 WARREN AVE
Practice Address - Street 2:
Practice Address - City:HO HO KUS
Practice Address - State:NJ
Practice Address - Zip Code:07423-1566
Practice Address - Country:US
Practice Address - Phone:201-251-2525
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-23
Last Update Date:2007-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA69017174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ3344304Medicaid
NJ3344304Medicaid
NJ026226Medicare ID - Type Unspecified