Provider Demographics
NPI:1629734355
Name:CANNON, MELINDA (FNP-C)
Entity Type:Individual
Prefix:
First Name:MELINDA
Middle Name:
Last Name:CANNON
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14590 STATE ROUTE 93
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:OH
Mailing Address - Zip Code:45640-8977
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:14590 STATE ROUTE 93
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:OH
Practice Address - Zip Code:45640-8977
Practice Address - Country:US
Practice Address - Phone:740-286-2826
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-17
Last Update Date:2022-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAPRN.CNP.0030096363LP2300X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0469216Medicaid