Provider Demographics
NPI:1740915909
Name:CANNON, GREG SAMUEL (MS, RD)
Entity type:Individual
Prefix:
First Name:GREG
Middle Name:SAMUEL
Last Name:CANNON
Suffix:
Gender:M
Credentials:MS, RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2635 TEPEE AVE SE
Mailing Address - Street 2:
Mailing Address - City:PALM BAY
Mailing Address - State:FL
Mailing Address - Zip Code:32909-7282
Mailing Address - Country:US
Mailing Address - Phone:321-720-8920
Mailing Address - Fax:
Practice Address - Street 1:2635 TEPEE AVE SE
Practice Address - Street 2:
Practice Address - City:PALM BAY
Practice Address - State:FL
Practice Address - Zip Code:32909-7282
Practice Address - Country:US
Practice Address - Phone:321-720-8920
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-21
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLND6331133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered