Provider Demographics
NPI:1063746402
Name:CANNON, KRISTEN NICOLE (LPN)
Entity type:Individual
Prefix:MRS
First Name:KRISTEN
Middle Name:NICOLE
Last Name:CANNON
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6 TRAIL RD
Mailing Address - Street 2:
Mailing Address - City:HURLEY
Mailing Address - State:NY
Mailing Address - Zip Code:12443-5034
Mailing Address - Country:US
Mailing Address - Phone:845-802-0230
Mailing Address - Fax:
Practice Address - Street 1:6 TRAIL RD
Practice Address - Street 2:
Practice Address - City:HURLEY
Practice Address - State:NY
Practice Address - Zip Code:12443-5034
Practice Address - Country:US
Practice Address - Phone:845-802-0230
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-01
Last Update Date:2009-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1029485164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse