Provider Demographics
NPI:1841434859
Name:VONCANNON, ROGER DALE (RN)
Entity type:Individual
Prefix:MR
First Name:ROGER
Middle Name:DALE
Last Name:VONCANNON
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2916 CLINE SCHOOL RD
Mailing Address - Street 2:
Mailing Address - City:CONCORD
Mailing Address - State:NC
Mailing Address - Zip Code:28025-7341
Mailing Address - Country:US
Mailing Address - Phone:704-791-7102
Mailing Address - Fax:
Practice Address - Street 1:2085 FRONTIS PLAZA BLVD
Practice Address - Street 2:NOVANT HEALTH
Practice Address - City:WINSTON-SALEM,
Practice Address - State:NC
Practice Address - Zip Code:27103
Practice Address - Country:US
Practice Address - Phone:336-718-5402
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-04-22
Last Update Date:2009-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC221866O163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse