Provider Demographics
NPI:1881625416
Name:CANNON, ANASTASIA R (ABOC)
Entity type:Individual
Prefix:MS
First Name:ANASTASIA
Middle Name:R
Last Name:CANNON
Suffix:
Gender:F
Credentials:ABOC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 687
Mailing Address - Street 2:
Mailing Address - City:EXMORE
Mailing Address - State:VA
Mailing Address - Zip Code:23350-0687
Mailing Address - Country:US
Mailing Address - Phone:757-442-3937
Mailing Address - Fax:757-442-5008
Practice Address - Street 1:3297 BROAD STREET
Practice Address - Street 2:
Practice Address - City:EXMORE
Practice Address - State:VA
Practice Address - Zip Code:23350-0687
Practice Address - Country:US
Practice Address - Phone:757-442-3937
Practice Address - Fax:757-442-5008
Is Sole Proprietor?:No
Enumeration Date:2006-07-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA001916156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician