Provider Demographics
NPI:1568417376
Name:CANNON, LAURA J (APRN)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:J
Last Name:CANNON
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:127 SO. 500 EAST #600
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84102-1971
Mailing Address - Country:US
Mailing Address - Phone:801-587-6705
Mailing Address - Fax:801-715-8228
Practice Address - Street 1:1950 CIRCLE OF HOPE
Practice Address - Street 2:CLINIC 1A
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84112-5550
Practice Address - Country:US
Practice Address - Phone:801-585-0100
Practice Address - Fax:801-585-7902
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-23
Last Update Date:2021-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT269735-4405163WX0800X, 363LC0200X, 363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No163WX0800XNursing Service ProvidersRegistered NurseOrthopedic
No363LC0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerCritical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTD5804Medicaid
UT005570908Medicare ID - Type Unspecified
UTD5804Medicaid