Provider Demographics
NPI:1447679097
Name:CANNON, LAINA (RD)
Entity type:Individual
Prefix:
First Name:LAINA
Middle Name:
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:PO BOX 241889
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99524-1889
Mailing Address - Country:US
Mailing Address - Phone:907-563-1777
Mailing Address - Fax:907-561-7464
Practice Address - Street 1:3260 PROVIDENCE DR
Practice Address - Street 2:STE 528
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99508-4661
Practice Address - Country:US
Practice Address - Phone:907-770-7213
Practice Address - Fax:907-770-7214
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-10
Last Update Date:2016-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK174133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered