Provider Demographics
NPI:1063965077
Name:CANNON, CARRIE
Entity type:Individual
Prefix:
First Name:CARRIE
Middle Name:
Last Name:CANNON
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6700 E SPEEDWAY, #123
Mailing Address - Street 2:1620 S PLACITA CHURELLA, TUCSON, AZ 85748
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85710-0000
Mailing Address - Country:US
Mailing Address - Phone:520-820-9282
Mailing Address - Fax:866-403-5117
Practice Address - Street 1:50 E CROYDON PARK RD
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85704-5792
Practice Address - Country:US
Practice Address - Phone:520-696-3438
Practice Address - Fax:520-888-2347
Is Sole Proprietor?:No
Enumeration Date:2016-07-26
Last Update Date:2025-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZTAP8850363L00000X
AZAP8850363LF0000X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily