Basic Information
| Provider Information | |||||||||
| NPI: | 1518338839 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CANNION | ||||||||
| FirstName: | LAKEECIA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DNP, ARNP-C | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | GREEN MILBRY | ||||||||
| OtherFirstName: | LAKEECIA | ||||||||
| OtherMiddleName: | CHANELL | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | DNP, APRN-C | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 60976 | ||||||||
| Address2: | |||||||||
| City: | PALM BAY | ||||||||
| State: | FL | ||||||||
| PostalCode: | 329060976 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3217957386 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 775 MALABAR RD | ||||||||
| Address2: | |||||||||
| City: | MALABAR | ||||||||
| State: | FL | ||||||||
| PostalCode: | 329503120 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3217228435 | ||||||||
| FaxNumber: | 3217228486 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/13/2015 | ||||||||
| LastUpdateDate: | 05/22/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 05/22/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2200X | ARNP9171717 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health | 163W00000X | RN9171717 | FL | N | Nursing Service Providers | Registered Nurse |
ID Information
| ID | Type | State | Issuer | Description | 016947100 | 05 | FL | MEDICAID |