Provider Demographics
NPI:1154202968
Name:CANNON, EBONY
Entity type:Individual
Prefix:
First Name:EBONY
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 1:16430 PARK LAKE RD LOT 72
Mailing Address - Street 2:
Mailing Address - City:EAST LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48823-9460
Mailing Address - Country:US
Mailing Address - Phone:517-802-0092
Mailing Address - Fax:
Practice Address - Street 1:16430 PARK LAKE RD LOT 72
Practice Address - Street 2:
Practice Address - City:EAST LANSING
Practice Address - State:MI
Practice Address - Zip Code:48823-9460
Practice Address - Country:US
Practice Address - Phone:517-802-0092
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-09-09
Last Update Date:2025-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI374J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes374J00000XNursing Service Related ProvidersDoulaGroup - Multi-Specialty