Provider Demographics
NPI:1790148765
Name:CANNON, LAURA
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:
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 1:1601 TRINITY ST
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78712-1765
Mailing Address - Country:US
Mailing Address - Phone:512-495-5717
Mailing Address - Fax:512-495-5709
Practice Address - Street 1:1601 TRINITY ST
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78712-1765
Practice Address - Country:US
Practice Address - Phone:512-495-5717
Practice Address - Fax:512-495-5709
Is Sole Proprietor?:No
Enumeration Date:2016-03-29
Last Update Date:2020-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
TX65478183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program