Provider Demographics
NPI:1194259564
Name:CANNON, KAREN
Entity type:Individual
Prefix:
First Name:KAREN
Middle Name:
Last Name:CANNON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:183 MORNINGSIDE DR
Mailing Address - Street 2:
Mailing Address - City:ST MATTHEWS
Mailing Address - State:SC
Mailing Address - Zip Code:29135-9226
Mailing Address - Country:US
Mailing Address - Phone:803-874-1816
Mailing Address - Fax:803-874-1816
Practice Address - Street 1:183 MORNINGSIDE DR
Practice Address - Street 2:
Practice Address - City:ST MATTHEWS
Practice Address - State:SC
Practice Address - Zip Code:29135-9226
Practice Address - Country:US
Practice Address - Phone:803-874-1816
Practice Address - Fax:803-874-1816
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-12
Last Update Date:2017-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator