Provider Demographics
NPI:1689281677
Name:CANNON, NOLA (RDN, LD)
Entity Type:Individual
Prefix:MS
First Name:NOLA
Middle Name:
Last Name:CANNON
Suffix:
Gender:F
Credentials:RDN, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:29677 HURTZ ROAD
Mailing Address - Street 2:
Mailing Address - City:PARMA
Mailing Address - State:ID
Mailing Address - Zip Code:83660
Mailing Address - Country:US
Mailing Address - Phone:208-504-9828
Mailing Address - Fax:
Practice Address - Street 1:29677 HURTZ ROAD
Practice Address - Street 2:
Practice Address - City:PARMA
Practice Address - State:ID
Practice Address - Zip Code:83660
Practice Address - Country:US
Practice Address - Phone:208-504-9828
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-24
Last Update Date:2024-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD-990133NN1002X, 133VN1201X, 133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
No133NN1002XDietary & Nutritional Service ProvidersNutritionistNutrition, Education
No133VN1201XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Obesity and Weight Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDD-990OtherLICENSED DIETITIAN