Provider Demographics
NPI:1104432160
Name:CANNON, EMILY BORDELEAU (RDN)
Entity type:Individual
Prefix:
First Name:EMILY
Middle Name:BORDELEAU
Last Name:CANNON
Suffix:
Gender:F
Credentials:RDN
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 308
Mailing Address - Street 2:
Mailing Address - City:RUTHERFORD COLLEGE
Mailing Address - State:NC
Mailing Address - Zip Code:28671-0308
Mailing Address - Country:US
Mailing Address - Phone:828-455-1699
Mailing Address - Fax:
Practice Address - Street 1:721-D MALCOM BLVD
Practice Address - Street 2:
Practice Address - City:RUTHERFORD COLLEGE
Practice Address - State:NC
Practice Address - Zip Code:28671
Practice Address - Country:US
Practice Address - Phone:828-455-1699
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-16
Last Update Date:2020-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC86119367133NN1002X, 133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
No133NN1002XDietary & Nutritional Service ProvidersNutritionistNutrition, Education