Provider Demographics
NPI:1043023187
Name:CANNON, MICHELLE IRENE (RD)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:IRENE
Last Name:CANNON
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1480 W WATERFRONT DR
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:UT
Mailing Address - Zip Code:84075-3803
Mailing Address - Country:US
Mailing Address - Phone:509-330-0878
Mailing Address - Fax:
Practice Address - Street 1:1480 W WATERFRONT DR
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:UT
Practice Address - Zip Code:84075-3803
Practice Address - Country:US
Practice Address - Phone:509-330-0878
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-01-31
Last Update Date:2025-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT13954808-4901133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered