Provider Demographics
NPI:1699842955
Name:CANNON, CHERYL LYNN
Entity Type:Individual
Prefix:MRS
First Name:CHERYL
Middle Name:LYNN
Last Name:CANNON
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:CHERYL
Other - Middle Name:LYNN
Other - Last Name:WALLACE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:17031 HARMONY DR
Mailing Address - Street 2:
Mailing Address - City:HUDSON
Mailing Address - State:FL
Mailing Address - Zip Code:34667
Mailing Address - Country:US
Mailing Address - Phone:727-379-3878
Mailing Address - Fax:
Practice Address - Street 1:14134 US HWY 19 N
Practice Address - Street 2:
Practice Address - City:HUDSON
Practice Address - State:FL
Practice Address - Zip Code:34667
Practice Address - Country:US
Practice Address - Phone:727-869-3114
Practice Address - Fax:727-861-2412
Is Sole Proprietor?:No
Enumeration Date:2006-11-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL2501 0103 0351 652183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
1074145Medicare UPIN
FL0556050370Medicare ID - Type Unspecified