Provider Demographics
NPI:1003105974
Name:CUNNINGHAM, CLARE N (PTA)
Entity Type:Individual
Prefix:MRS
First Name:CLARE
Middle Name:N
Last Name:CUNNINGHAM
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:MISS
Other - First Name:CLARE
Other - Middle Name:N
Other - Last Name:FORD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PTA
Mailing Address - Street 1:1405 N. MOUNT AUBURN ROAD
Mailing Address - Street 2:
Mailing Address - City:CAPE GIRARDEAU
Mailing Address - State:MO
Mailing Address - Zip Code:63701
Mailing Address - Country:US
Mailing Address - Phone:573-335-7868
Mailing Address - Fax:573-335-8193
Practice Address - Street 1:1405 N. MOUNT AUBURN ROAD
Practice Address - Street 2:
Practice Address - City:CAPE GIRARDEAU
Practice Address - State:MO
Practice Address - Zip Code:63701
Practice Address - Country:US
Practice Address - Phone:573-335-7868
Practice Address - Fax:573-335-8193
Is Sole Proprietor?:No
Enumeration Date:2011-03-31
Last Update Date:2011-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2011006548225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant