Provider Demographics
NPI:1144748724
Name:CANNON, CASSANDRA
Entity Type:Individual
Prefix:
First Name:CASSANDRA
Middle Name:
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 1:5424 KILLENS POND RD
Mailing Address - Street 2:
Mailing Address - City:FELTON
Mailing Address - State:DE
Mailing Address - Zip Code:19943-1902
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5423 KILLENS POND RD
Practice Address - Street 2:
Practice Address - City:FELTON
Practice Address - State:DE
Practice Address - Zip Code:19943-1901
Practice Address - Country:US
Practice Address - Phone:302-284-5810
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-05
Last Update Date:2017-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEJ20000994225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
DEJ2-0000994OtherSTATE OF DELAWARE