Provider Demographics
NPI:1720319130
Name:CANNON, EMILY J (ACNP)
Entity Type:Individual
Prefix:
First Name:EMILY
Middle Name:J
Last Name:CANNON
Suffix:
Gender:F
Credentials:ACNP
Other - Prefix:
Other - First Name:EMILY
Other - Middle Name:J
Other - Last Name:EVANS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 846098
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-6098
Mailing Address - Country:US
Mailing Address - Phone:903-324-6400
Mailing Address - Fax:903-592-9986
Practice Address - Street 1:619 S FLEISHEL AVE
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75701-2004
Practice Address - Country:US
Practice Address - Phone:903-606-1264
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-01-25
Last Update Date:2023-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP118873363L00000X
TX723802363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXP02469301OtherMEDICARE RAIL ROAD
TX1C3376OtherMEDICARE
TX8MK526OtherBCBS
TX398191220Medicaid