Provider Demographics
NPI:1811328313
Name:KANNER, AMY
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:
Last Name:KANNER
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 1:11340 CAMINO PLAYA CANCUN UNIT 7
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92124-1580
Mailing Address - Country:US
Mailing Address - Phone:619-253-4277
Mailing Address - Fax:
Practice Address - Street 1:11340 CAMINO PLAYA CANCUN UNIT 7
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92124-1580
Practice Address - Country:US
Practice Address - Phone:619-253-4277
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-12-09
Last Update Date:2013-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG52145207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine