Provider Demographics
NPI:1821634296
Name:CANNON, ALISSA G
Entity type:Individual
Prefix:
First Name:ALISSA
Middle Name:G
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 1:2321 PLANTER RIDGE CT SE
Mailing Address - Street 2:
Mailing Address - City:PALM BAY
Mailing Address - State:FL
Mailing Address - Zip Code:32909-6850
Mailing Address - Country:US
Mailing Address - Phone:321-514-7080
Mailing Address - Fax:
Practice Address - Street 1:2324 STATE ROAD 524
Practice Address - Street 2:
Practice Address - City:COCOA
Practice Address - State:FL
Practice Address - Zip Code:32926-5893
Practice Address - Country:US
Practice Address - Phone:321-636-9335
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-20
Last Update Date:2025-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPSI48038390200000X
FLRPT53347183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No183700000XPharmacy Service ProvidersPharmacy Technician