Provider Demographics
NPI:1376783332
Name:CANNON, BONNIE M (OTA)
Entity Type:Individual
Prefix:
First Name:BONNIE
Middle Name:M
Last Name:CANNON
Suffix:
Gender:F
Credentials:OTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1330 SCHNEIDER RD
Mailing Address - Street 2:
Mailing Address - City:BLAND
Mailing Address - State:MO
Mailing Address - Zip Code:65014-2308
Mailing Address - Country:US
Mailing Address - Phone:615-896-6400
Mailing Address - Fax:
Practice Address - Street 1:1899 HIGHWAY 63
Practice Address - Street 2:
Practice Address - City:WESTPHALIA
Practice Address - State:MO
Practice Address - Zip Code:65085-2215
Practice Address - Country:US
Practice Address - Phone:615-896-6400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-03-03
Last Update Date:2009-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2001010113224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant