Provider Demographics
NPI:1811609167
Name:CANNON, LACEY JO
Entity type:Individual
Prefix:
First Name:LACEY
Middle Name:JO
Last Name:CANNON
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 1:1952 NEW CREEK HWY
Mailing Address - Street 2:
Mailing Address - City:KEYSER
Mailing Address - State:WV
Mailing Address - Zip Code:26726-7494
Mailing Address - Country:US
Mailing Address - Phone:304-597-3522
Mailing Address - Fax:
Practice Address - Street 1:1952 NEW CREEK HWY
Practice Address - Street 2:
Practice Address - City:KEYSER
Practice Address - State:WV
Practice Address - Zip Code:26726-7494
Practice Address - Country:US
Practice Address - Phone:304-597-1258
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-12-19
Last Update Date:2022-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV70974374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV70974Medicaid