Provider Demographics
NPI:1649768425
Name:CANNON, KERRI M
Entity Type:Individual
Prefix:
First Name:KERRI
Middle Name:M
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 1:615 W NURSERY ST
Mailing Address - Street 2:
Mailing Address - City:BUTLER
Mailing Address - State:MO
Mailing Address - Zip Code:64730-1840
Mailing Address - Country:US
Mailing Address - Phone:913-210-8384
Mailing Address - Fax:
Practice Address - Street 1:615 W NURSERY ST
Practice Address - Street 2:
Practice Address - City:BUTLER
Practice Address - State:MO
Practice Address - Zip Code:64730-1840
Practice Address - Country:US
Practice Address - Phone:913-210-8384
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-26
Last Update Date:2018-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered