Provider Demographics
NPI:1699545277
Name:CANNON, KEONA (TBA,FSD IBCLC,CHW)
Entity type:Individual
Prefix:
First Name:KEONA
Middle Name:
Last Name:CANNON
Suffix:
Gender:F
Credentials:TBA,FSD IBCLC,CHW
Other - Prefix:MS
Other - First Name:GODDIS
Other - Middle Name:
Other - Last Name:KE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:HPP,TBA,DHT,CCH
Mailing Address - Street 1:1 TAMPA GENERAL CIR
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33606-3571
Mailing Address - Country:US
Mailing Address - Phone:314-591-3118
Mailing Address - Fax:
Practice Address - Street 1:1 TAMPA GENERAL CIR
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33606-3571
Practice Address - Country:US
Practice Address - Phone:314-591-3118
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-04
Last Update Date:2024-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
172V00000X, 174H00000X, 171M00000X, 175F00000X, 175M00000X, 101YM0800X, 133NN1002X, 171100000X, 225700000X, 253Z00000X, 374K00000X, 374J00000X
GAMBQ0171207VH0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374J00000XNursing Service Related ProvidersDoula
No172V00000XOther Service ProvidersCommunity Health Worker
No174H00000XOther Service ProvidersHealth Educator
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
No175F00000XOther Service ProvidersNaturopath
No175M00000XOther Service ProvidersMidwife, Lay
No207VH0002XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyHospice and Palliative Medicine
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No133NN1002XDietary & Nutritional Service ProvidersNutritionistNutrition, Education
No171100000XOther Service ProvidersAcupuncturist
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
No253Z00000XAgenciesIn Home Supportive Care
No374K00000XNursing Service Related ProvidersReligious Nonmedical Practitioner