Provider Demographics
NPI:1932850286
Name:CANNON, VICTORIA CANNON (71400000X)
Entity type:Individual
Prefix:MRS
First Name:VICTORIA
Middle Name:CANNON
Last Name:CANNON
Suffix:
Gender:F
Credentials:71400000X
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:622 10TH ST
Mailing Address - Street 2:
Mailing Address - City:HERMOSA BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90254-3930
Mailing Address - Country:US
Mailing Address - Phone:310-955-0900
Mailing Address - Fax:
Practice Address - Street 1:622 10TH ST
Practice Address - Street 2:
Practice Address - City:HERMOSA BEACH
Practice Address - State:CA
Practice Address - Zip Code:90254-3930
Practice Address - Country:US
Practice Address - Phone:310-955-0900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-18
Last Update Date:2022-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA171400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171400000XOther Service ProvidersHealth & Wellness Coach
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA71400000XOtherNBHWC