Provider Demographics
NPI:1427702331
Name:CANNON, KENDALL (NP)
Entity type:Individual
Prefix:
First Name:KENDALL
Middle Name:
Last Name:CANNON
Suffix:
Gender:
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3050 WHITE SANDS CT
Mailing Address - Street 2:
Mailing Address - City:HOLLOMAN AIR FORCE BASE
Mailing Address - State:NM
Mailing Address - Zip Code:88330-8132
Mailing Address - Country:US
Mailing Address - Phone:301-268-3020
Mailing Address - Fax:
Practice Address - Street 1:280 DAVID L GOLDFEIN ST BLDG 23
Practice Address - Street 2:
Practice Address - City:HOLLOMAN AFB
Practice Address - State:NM
Practice Address - Zip Code:88330-8273
Practice Address - Country:US
Practice Address - Phone:575-572-2778
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-09
Last Update Date:2025-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR203938363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health