Provider Demographics
NPI:1295390177
Name:CANNON, NICHOLE LYNN (CCC-SLP)
Entity type:Individual
Prefix:
First Name:NICHOLE
Middle Name:LYNN
Last Name:CANNON
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9415 MONTGOMERY RD
Mailing Address - Street 2:
Mailing Address - City:MONTGOMERY
Mailing Address - State:OH
Mailing Address - Zip Code:45242-7656
Mailing Address - Country:US
Mailing Address - Phone:513-652-0062
Mailing Address - Fax:
Practice Address - Street 1:9415 MONTGOMERY RD
Practice Address - Street 2:SUITE C
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45242-7641
Practice Address - Country:US
Practice Address - Phone:513-652-0062
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-06
Last Update Date:2024-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHSP.08789235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist