Basic Information
| Provider Information | |||||||||
| NPI: | 1568417376 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CANNON | ||||||||
| FirstName: | LAURA | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | APRN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 127 SO. 500 EAST #600 | ||||||||
| Address2: | |||||||||
| City: | SALT LAKE CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841021971 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8015876705 | ||||||||
| FaxNumber: | 8017158228 | ||||||||
| Practice Location | |||||||||
| Address1: | 1950 CIRCLE OF HOPE | ||||||||
| Address2: | CLINIC 1A | ||||||||
| City: | SALT LAKE CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841125550 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8015850100 | ||||||||
| FaxNumber: | 8015857902 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/23/2006 | ||||||||
| LastUpdateDate: | 11/11/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 11/11/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163WX0800X | 269735-4405 | UT | N | Nursing Service Providers | Registered Nurse | Orthopedic | 363LC0200X | 269735-4405 | UT | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Critical Care Medicine | 363LA2200X | 269735-4405 | UT | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health |
ID Information
| ID | Type | State | Issuer | Description | D5804 | 05 | UT | MEDICAID |