Provider Demographics
NPI:1689080384
Name:CANNON, VERONICA LEA (APRN)
Entity Type:Individual
Prefix:
First Name:VERONICA
Middle Name:LEA
Last Name:CANNON
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1604 MLK BLVD
Mailing Address - Street 2:
Mailing Address - City:MALVERN
Mailing Address - State:AR
Mailing Address - Zip Code:72104
Mailing Address - Country:US
Mailing Address - Phone:501-732-5400
Mailing Address - Fax:501-325-9650
Practice Address - Street 1:1604 MLK BLVD
Practice Address - Street 2:
Practice Address - City:MALVERN
Practice Address - State:AR
Practice Address - Zip Code:72104
Practice Address - Country:US
Practice Address - Phone:501-732-5400
Practice Address - Fax:501-325-9650
Is Sole Proprietor?:No
Enumeration Date:2014-07-02
Last Update Date:2024-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARA004099363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR204425758Medicaid
AR361454YJG2Medicare Oscar/Certification
AR204425758Medicaid