Provider Demographics
NPI:1578940656
Name:CANNON, KIMBERLY (AGPCNP-BC)
Entity Type:Individual
Prefix:MRS
First Name:KIMBERLY
Middle Name:
Last Name:CANNON
Suffix:
Gender:F
Credentials:AGPCNP-BC
Other - Prefix:
Other - First Name:KIMBERLY
Other - Middle Name:
Other - Last Name:BUCHANAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:28315 HARPER AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT CLAIR SHORES
Mailing Address - State:MI
Mailing Address - Zip Code:48081-1687
Mailing Address - Country:US
Mailing Address - Phone:586-552-1710
Mailing Address - Fax:
Practice Address - Street 1:28315 HARPER AVE
Practice Address - Street 2:
Practice Address - City:SAINT CLAIR SHORES
Practice Address - State:MI
Practice Address - Zip Code:48081-1687
Practice Address - Country:US
Practice Address - Phone:586-552-1710
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-28
Last Update Date:2015-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704259824363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2014018630OtherAMERICAN NURSES CREDENTIALING CENTER CERTIFICATION
MI4704259824OtherSTATE OF MICHIGAN, BOARD OF NURSING, NURSE PRACTITIONER LICENSE