Provider Demographics
NPI:1700981651
Name:CANNON, REBECCA JOAN (DC)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:JOAN
Last Name:CANNON
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:405 N 1ST ST
Mailing Address - Street 2:SUITE 110
Mailing Address - City:HERMISTON
Mailing Address - State:OR
Mailing Address - Zip Code:97838-1843
Mailing Address - Country:US
Mailing Address - Phone:541-567-0944
Mailing Address - Fax:541-567-7266
Practice Address - Street 1:405 N 1ST ST
Practice Address - Street 2:SUITE 110
Practice Address - City:HERMISTON
Practice Address - State:OR
Practice Address - Zip Code:97838-1843
Practice Address - Country:US
Practice Address - Phone:541-567-0944
Practice Address - Fax:541-567-7266
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-14
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR2732111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR001304000OtherBCBS
ORU25561Medicare UPIN
OR112347Medicare ID - Type Unspecified