Provider Demographics
NPI:1255724423
Name:CANNON, DANA (COSMETOLOGIST)
Entity type:Individual
Prefix:
First Name:DANA
Middle Name:
Last Name:CANNON
Suffix:
Gender:F
Credentials:COSMETOLOGIST
Other - Prefix:
Other - First Name:DANA
Other - Middle Name:
Other - Last Name:CANNON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:COSMETOLOGIST
Mailing Address - Street 1:2805 SOUTH BLVD
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28209-1801
Mailing Address - Country:US
Mailing Address - Phone:704-527-0200
Mailing Address - Fax:
Practice Address - Street 1:2805 SOUTH BLVD
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28209-1801
Practice Address - Country:US
Practice Address - Phone:704-527-0200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-03-12
Last Update Date:2015-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC32293224P00000X
NCC92801224P00000X
GAC0120769224P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224P00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersProsthetist