Provider Demographics
NPI:1447996517
Name:CANNON, ASHLEY
Entity type:Individual
Prefix:
First Name:ASHLEY
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 1:714 PINE MANOR DR
Mailing Address - Street 2:
Mailing Address - City:HAMBURG
Mailing Address - State:AR
Mailing Address - Zip Code:71646-3313
Mailing Address - Country:US
Mailing Address - Phone:870-853-7534
Mailing Address - Fax:
Practice Address - Street 1:319 W PARKER ST
Practice Address - Street 2:
Practice Address - City:HAMBURG
Practice Address - State:AR
Practice Address - Zip Code:71646-3121
Practice Address - Country:US
Practice Address - Phone:870-853-8271
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-10
Last Update Date:2023-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARF05220215363LF0000X
AR220179363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner