Provider Demographics
NPI:1760968804
Name:CANNON, AMANDA GRAVES (FNP)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:GRAVES
Last Name:CANNON
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1900 N STATE ST STE 103
Mailing Address - Street 2:
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84604-1354
Mailing Address - Country:US
Mailing Address - Phone:801-669-5758
Mailing Address - Fax:
Practice Address - Street 1:1900 N STATE ST STE 103
Practice Address - Street 2:
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84604-1354
Practice Address - Country:US
Practice Address - Phone:801-669-5758
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-12
Last Update Date:2020-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT9111041-4405363LF0000X
UT911041363LX0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LX0001XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerObstetrics & Gynecology
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily