Provider Demographics
NPI:1801696380
Name:CANNON, JACQUELINE FELICIA (APRN, AGPCNP)
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:FELICIA
Last Name:CANNON
Suffix:
Gender:
Credentials:APRN, AGPCNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:160 MINE LAKE CT STE 200
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27615-6417
Mailing Address - Country:US
Mailing Address - Phone:919-630-3936
Mailing Address - Fax:
Practice Address - Street 1:160 MINE LAKE CT STE 200
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27615-6417
Practice Address - Country:US
Practice Address - Phone:855-984-5121
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-03-14
Last Update Date:2025-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5021868363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology