Provider Demographics
NPI:1891718078
Name:CANNON, NANCY A (PSYD)
Entity Type:Individual
Prefix:
First Name:NANCY
Middle Name:A
Last Name:CANNON
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11520 N PORT WASHINGTON ROAD
Mailing Address - Street 2:SUITE 108
Mailing Address - City:MEQUON
Mailing Address - State:WI
Mailing Address - Zip Code:53092-3352
Mailing Address - Country:US
Mailing Address - Phone:414-803-9967
Mailing Address - Fax:
Practice Address - Street 1:11520 N PORT WASHINGTON ROAD
Practice Address - Street 2:SUITE 108
Practice Address - City:MEQUON
Practice Address - State:WI
Practice Address - Zip Code:53092-3352
Practice Address - Country:US
Practice Address - Phone:414-803-9967
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2523057103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical