Provider Demographics
NPI:1609853043
Name:CANNON, KATHERINE ELLIOTT
Entity type:Individual
Prefix:
First Name:KATHERINE
Middle Name:ELLIOTT
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 1:1517 CARTER ST
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23220-6903
Mailing Address - Country:US
Mailing Address - Phone:804-920-4277
Mailing Address - Fax:
Practice Address - Street 1:1465 JOHNSTON WILLIS DR
Practice Address - Street 2:
Practice Address - City:NORTH CHESTERFIELD
Practice Address - State:VA
Practice Address - Zip Code:23235-4730
Practice Address - Country:US
Practice Address - Phone:804-320-3668
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-28
Last Update Date:2016-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305204298225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
008806A64Medicare ID - Type Unspecified