Provider Demographics
NPI:1184270209
Name:CANNON, KELLY (APRN, FNP-BC)
Entity type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:
Last Name:CANNON
Suffix:
Gender:F
Credentials:APRN, FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:210 JUPITER LAKES BLVD STE 4105
Mailing Address - Street 2:
Mailing Address - City:JUPITER
Mailing Address - State:FL
Mailing Address - Zip Code:33458-7190
Mailing Address - Country:US
Mailing Address - Phone:561-743-9938
Mailing Address - Fax:561-575-0801
Practice Address - Street 1:1700 S 23RD ST
Practice Address - Street 2:
Practice Address - City:FORT PIERCE
Practice Address - State:FL
Practice Address - Zip Code:34950-4803
Practice Address - Country:US
Practice Address - Phone:772-461-4000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-14
Last Update Date:2024-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN11005031363L00000X
FLRN9312491163WE0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163WE0003XNursing Service ProvidersRegistered NurseEmergency
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1184270209OtherMEDICARE MEDICAID AND OTHER