Provider Demographics
NPI:1558179515
Name:CANNON, QUANISHA
Entity type:Individual
Prefix:
First Name:QUANISHA
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 1:3702 W SPRUCE ST # 1117
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33607-2553
Mailing Address - Country:US
Mailing Address - Phone:800-303-4214
Mailing Address - Fax:
Practice Address - Street 1:3702 W SPRUCE ST # 1117
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33607-2553
Practice Address - Country:US
Practice Address - Phone:800-303-4214
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-12-23
Last Update Date:2025-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171400000X, 172V00000X, 175F00000X, 175L00000X, 106S00000X, 133NN1002X, 251B00000X, 251G00000X, 251S00000X, 332B00000X, 374J00000X, 374K00000X
FLQC23WF51222081N0008X
MOIM12QC56970202D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes202D00000XAllopathic & Osteopathic PhysiciansIntegrative Medicine
No171400000XOther Service ProvidersHealth & Wellness Coach
No172V00000XOther Service ProvidersCommunity Health Worker
No175F00000XOther Service ProvidersNaturopath
No175L00000XOther Service ProvidersHomeopath
No2081N0008XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationNeuromuscular Medicine
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No133NN1002XDietary & Nutritional Service ProvidersNutritionistNutrition, Education
No251B00000XAgenciesCase Management
No251G00000XAgenciesHospice Care, Community Based
No251S00000XAgenciesCommunity/Behavioral Health
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No374J00000XNursing Service Related ProvidersDoula
No374K00000XNursing Service Related ProvidersReligious Nonmedical Practitioner