Provider Demographics
NPI:1841090693
Name:CANNON, MONIQUE M
Entity type:Individual
Prefix:
First Name:MONIQUE
Middle Name:M
Last Name:CANNON
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10245 PEPPERIDGE DR
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46235-1242
Mailing Address - Country:US
Mailing Address - Phone:317-361-7923
Mailing Address - Fax:
Practice Address - Street 1:352 TANGLEWOOD DR
Practice Address - Street 2:
Practice Address - City:DAVENPORT
Practice Address - State:FL
Practice Address - Zip Code:33896-3106
Practice Address - Country:US
Practice Address - Phone:317-361-7923
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-03-18
Last Update Date:2025-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL240448376J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376J00000XNursing Service Related ProvidersHomemaker