Provider Demographics
NPI:1922497957
Name:CANNON, KATHERINE CLIFTON (RD)
Entity Type:Individual
Prefix:
First Name:KATHERINE
Middle Name:CLIFTON
Last Name:CANNON
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:KATE
Other - Middle Name:C
Other - Last Name:CANNON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:RD
Mailing Address - Street 1:PO BOX 18563
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27619-8563
Mailing Address - Country:US
Mailing Address - Phone:919-782-1806
Mailing Address - Fax:919-782-4756
Practice Address - Street 1:3521 HAWORTH DR
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27609-7244
Practice Address - Country:US
Practice Address - Phone:919-782-1806
Practice Address - Fax:919-782-4756
Is Sole Proprietor?:No
Enumeration Date:2015-01-14
Last Update Date:2015-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCL003467133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered