Provider Demographics
NPI:1528789997
Name:CANNON, LEPORSCHE MARQUITA
Entity type:Individual
Prefix:MRS
First Name:LEPORSCHE
Middle Name:MARQUITA
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 1:205 DENTAL DR STE 11
Mailing Address - Street 2:
Mailing Address - City:WARNER ROBINS
Mailing Address - State:GA
Mailing Address - Zip Code:31088-8216
Mailing Address - Country:US
Mailing Address - Phone:478-334-2091
Mailing Address - Fax:
Practice Address - Street 1:205 DENTAL DR STE 11
Practice Address - Street 2:
Practice Address - City:WARNER ROBINS
Practice Address - State:GA
Practice Address - Zip Code:31088-8216
Practice Address - Country:US
Practice Address - Phone:478-334-2091
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-06
Last Update Date:2022-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier