1609612100 NPI number — CANNON HEALTH

Table of content: (NPI 1609612100)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1609612100 NPI number — CANNON HEALTH

Organization/Personal Information

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

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:
1609612100
Entity Type Code:
Organization
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:
1620 S PLACITA CHURELLA
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TUCSON
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85748-7714
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
520-800-9282
Provider Business Mailing Address Fax Number:
866-403-5117

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6700 E SPEEDWAY BLVD.
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:
85710
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
520-800-9282
Provider Business Practice Location Address Fax Number:
866-403-5117
Provider Enumeration Date:
07/03/2024

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
CANNON
Authorized Official First Name:
CARRIE
Authorized Official Middle Name:
EILEEN
Authorized Official Title or Position:
PMHNP-BC, FNP-C, CKNS
Authorized Official Telephone Number:
520-800-9282

Provider Taxonomy Codes

  • Taxonomy code: 363LP0808X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LF0000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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