Provider Demographics
NPI:1821978636
Name:CANNON, AVERY MICHELLE (RDN, LD)
Entity type:Individual
Prefix:
First Name:AVERY
Middle Name:MICHELLE
Last Name:CANNON
Suffix:
Gender:F
Credentials:RDN, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:511 NW 29TH ST APT 1
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73103-1049
Mailing Address - Country:US
Mailing Address - Phone:918-257-9760
Mailing Address - Fax:
Practice Address - Street 1:16308 IRONSTONE DR
Practice Address - Street 2:
Practice Address - City:EDMOND
Practice Address - State:OK
Practice Address - Zip Code:73013-6089
Practice Address - Country:US
Practice Address - Phone:405-885-0270
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-09-03
Last Update Date:2025-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK3195133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered