Provider Demographics
NPI:1124645007
Name:CANN, JOHN WILLIAM (MSN, FNP-BC, APRN)
Entity type:Individual
Prefix:MR
First Name:JOHN
Middle Name:WILLIAM
Last Name:CANN
Suffix:
Gender:M
Credentials:MSN, FNP-BC, APRN
Other - Prefix:MR
Other - First Name:JOHN
Other - Middle Name:WILLIAM
Other - Last Name:CANN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MSN, FNP-C, APRN
Mailing Address - Street 1:111 DERBY RD
Mailing Address - Street 2:
Mailing Address - City:REVERE
Mailing Address - State:MA
Mailing Address - Zip Code:02151-1803
Mailing Address - Country:US
Mailing Address - Phone:617-285-8731
Mailing Address - Fax:
Practice Address - Street 1:655 BROADWAY
Practice Address - Street 2:
Practice Address - City:REVERE
Practice Address - State:MA
Practice Address - Zip Code:02151-2347
Practice Address - Country:US
Practice Address - Phone:617-285-8731
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-26
Last Update Date:2022-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN2298986163WS0121X, 174H00000X, 363LA2100X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163WS0121XNursing Service ProvidersRegistered NursePlastic Surgery
No174H00000XOther Service ProvidersHealth Educator
No363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAS26425787Medicaid