Provider Demographics
NPI:1295164945
Name:CANYON, NANCY (LMP)
Entity type:Individual
Prefix:
First Name:NANCY
Middle Name:
Last Name:CANYON
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:910 HARRIS AVE # A206
Mailing Address - Street 2:
Mailing Address - City:BELLINGHAM
Mailing Address - State:WA
Mailing Address - Zip Code:98225-7008
Mailing Address - Country:US
Mailing Address - Phone:360-710-7139
Mailing Address - Fax:
Practice Address - Street 1:907 HARRIS AVE STE 203
Practice Address - Street 2:
Practice Address - City:BELLINGHAM
Practice Address - State:WA
Practice Address - Zip Code:98225-7005
Practice Address - Country:US
Practice Address - Phone:360-710-7139
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-04
Last Update Date:2013-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA8493172V00000X, 174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
No172V00000XOther Service ProvidersCommunity Health Worker