Provider Demographics
NPI:1619471554
Name:CANNON, LAURA
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:CANNON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4341 PIEDMONT AVE STE 201
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94611-4792
Mailing Address - Country:US
Mailing Address - Phone:510-547-1630
Mailing Address - Fax:
Practice Address - Street 1:4341 PIEDMONT AVE STE 201
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94611-4792
Practice Address - Country:US
Practice Address - Phone:510-547-1630
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-23
Last Update Date:2022-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT293972208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation