Provider Demographics
NPI:1902049398
Name:CANNON, ROBERT DAVIS (RN, CNS)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:DAVIS
Last Name:CANNON
Suffix:
Gender:M
Credentials:RN, CNS
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Other - First Name:
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Mailing Address - Street 1:PO BOX 3253
Mailing Address - Street 2:
Mailing Address - City:ALPHARETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30023-3253
Mailing Address - Country:US
Mailing Address - Phone:770-888-2524
Mailing Address - Fax:770-809-5063
Practice Address - Street 1:5665 PEACHTREE DUNWOODY RD NE
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30342-1764
Practice Address - Country:US
Practice Address - Phone:770-888-2524
Practice Address - Fax:770-809-5063
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-14
Last Update Date:2010-11-29
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
GARN051954364SP0809X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SP0809XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health, Adult
Provider Identifiers
StateIdentifier IDID TypeIssuer
202I893945Medicare PIN