Provider Demographics
NPI:1457810855
Name:CANNON, MAUREEN STORMONT (AUD)
Entity Type:Individual
Prefix:
First Name:MAUREEN
Middle Name:STORMONT
Last Name:CANNON
Suffix:
Gender:F
Credentials:AUD
Other - Prefix:
Other - First Name:MAUREEN
Other - Middle Name:KEEGAN
Other - Last Name:STORMONT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:765 HAMPDEN AVE APT 515
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55114-1672
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1390 UNIVERSITY AVE W
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55104-4001
Practice Address - Country:US
Practice Address - Phone:651-232-4800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-15
Last Update Date:2019-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN10074231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist