Provider Demographics
NPI:1902297880
Name:CANNON, JAIMIE SUZANNE (MSN, APRN, FNP-C)
Entity Type:Individual
Prefix:MRS
First Name:JAIMIE
Middle Name:SUZANNE
Last Name:CANNON
Suffix:
Gender:F
Credentials:MSN, APRN, FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6468 STATE HIGHWAY 77
Mailing Address - Street 2:
Mailing Address - City:BENTON
Mailing Address - State:MO
Mailing Address - Zip Code:63736-8237
Mailing Address - Country:US
Mailing Address - Phone:573-545-3565
Mailing Address - Fax:573-545-3491
Practice Address - Street 1:6468 STATE HIGHWAY 77
Practice Address - Street 2:
Practice Address - City:BENTON
Practice Address - State:MO
Practice Address - Zip Code:63736-8237
Practice Address - Country:US
Practice Address - Phone:573-545-3565
Practice Address - Fax:573-545-3491
Is Sole Proprietor?:No
Enumeration Date:2015-02-12
Last Update Date:2015-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2015004268363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily