Provider Demographics
NPI:1700110749
Name:CANNON, SHELLEY
Entity Type:Individual
Prefix:
First Name:SHELLEY
Middle Name:
Last Name:CANNON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9201 N 5TH ST
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85020-2532
Mailing Address - Country:US
Mailing Address - Phone:602-331-5779
Mailing Address - Fax:302-331-7855
Practice Address - Street 1:9201 N 5TH ST
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85020-2532
Practice Address - Country:US
Practice Address - Phone:602-331-5779
Practice Address - Fax:602-331-7855
Is Sole Proprietor?:No
Enumeration Date:2009-09-23
Last Update Date:2012-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAP3189363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ503287Medicaid