Provider Demographics
NPI:1194490755
Name:CANNON, DESLA D
Entity type:Individual
Prefix:
First Name:DESLA
Middle Name:D
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 1:1397 BRANDON AVE
Mailing Address - Street 2:
Mailing Address - City:AKRON
Mailing Address - State:OH
Mailing Address - Zip Code:44305-1850
Mailing Address - Country:US
Mailing Address - Phone:133-061-8983
Mailing Address - Fax:
Practice Address - Street 1:1397 BRANDON AVE
Practice Address - Street 2:
Practice Address - City:AKRON
Practice Address - State:OH
Practice Address - Zip Code:44305-1850
Practice Address - Country:US
Practice Address - Phone:330-618-9832
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-14
Last Update Date:2021-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide