Provider Demographics
NPI:1639123565
Name:CANNON, NICHOLAS (DC)
Entity Type:Individual
Prefix:DR
First Name:NICHOLAS
Middle Name:
Last Name:CANNON
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:152 MAPLE ST STE 302
Mailing Address - Street 2:
Mailing Address - City:MIDDLEBURY
Mailing Address - State:VT
Mailing Address - Zip Code:05753-1168
Mailing Address - Country:US
Mailing Address - Phone:802-458-0488
Mailing Address - Fax:802-458-0489
Practice Address - Street 1:152 MAPLE ST STE 302
Practice Address - Street 2:
Practice Address - City:MIDDLEBURY
Practice Address - State:VT
Practice Address - Zip Code:05753-1168
Practice Address - Country:US
Practice Address - Phone:802-458-0488
Practice Address - Fax:802-458-0489
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-22
Last Update Date:2022-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT006-0001191111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME010529023OtherMEDNET
MEAA57163OtherHARVARD PILGRIM
ME010529023OtherCBA/EBPA
ME100214OtherANTHEM
ME7333997OtherCIGNA
ME432127799Medicaid