Basic Information
| Provider Information | |||||||||
| NPI: | 1124313788 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CANNON | ||||||||
| FirstName: | NICOLE | ||||||||
| MiddleName: | MARIE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1008 N ROOSEVELT AVE | ||||||||
| Address2: | |||||||||
| City: | SAND SPRINGS | ||||||||
| State: | OK | ||||||||
| PostalCode: | 740637355 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3188053830 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 6333 E SKELLY DR | ||||||||
| Address2: | |||||||||
| City: | TULSA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 741356106 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9186644224 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/12/2011 | ||||||||
| LastUpdateDate: | 06/12/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 324500000X | Y | Residential Treatment Facilities | Substance Abuse Rehabilitation Facility |
No ID Information.