Provider Demographics
NPI:1760968804
Name:CANNON, AMANDA GRAVES (FNP)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:GRAVES
Last Name:CANNON
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:667 E 500 N STE 200
Mailing Address - Street 2:
Mailing Address - City:VINEYARD
Mailing Address - State:UT
Mailing Address - Zip Code:84059-6004
Mailing Address - Country:US
Mailing Address - Phone:801-669-5758
Mailing Address - Fax:801-216-8357
Practice Address - Street 1:667 E 500 N STE 200
Practice Address - Street 2:
Practice Address - City:VINEYARD
Practice Address - State:UT
Practice Address - Zip Code:84059-6004
Practice Address - Country:US
Practice Address - Phone:801-669-5758
Practice Address - Fax:801-216-8357
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-12
Last Update Date:2024-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT911041363LX0001X
UT9111041-4405363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LX0001XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerObstetrics & Gynecology