1063965077 NPI number — CARRIE CANNON

Table of content: CARRIE CANNON (NPI 1063965077)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063965077 NPI number — CARRIE CANNON

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CANNON
Provider First Name:
CARRIE
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1063965077
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/03/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6700 E SPEEDWAY, #123
Provider Second Line Business Mailing Address:
1620 S PLACITA CHURELLA, TUCSON, AZ 85748
Provider Business Mailing Address City Name:
TUCSON
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85710-0000
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
520-820-9282
Provider Business Mailing Address Fax Number:
866-403-5117

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
50 E CROYDON PARK RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TUCSON
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85704-5792
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
520-696-3438
Provider Business Practice Location Address Fax Number:
520-888-2347
Provider Enumeration Date:
07/26/2016

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363L00000X , with the licence number:  TAP8850 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LF0000X , with the licence number: AP8850 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LP0808X , with the licence number: AP8850 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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