Provider Demographics
NPI:1396370474
Name:CANNON, KRISTIN (OTR)
Entity Type:Individual
Prefix:
First Name:KRISTIN
Middle Name:
Last Name:CANNON
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5488 PENNYCRESS DR
Mailing Address - Street 2:
Mailing Address - City:NOBLESVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46062-0009
Mailing Address - Country:US
Mailing Address - Phone:812-661-0904
Mailing Address - Fax:
Practice Address - Street 1:7235 RIVERWALK WAY N
Practice Address - Street 2:
Practice Address - City:NOBLESVILLE
Practice Address - State:IN
Practice Address - Zip Code:46062-7001
Practice Address - Country:US
Practice Address - Phone:317-214-4307
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-09
Last Update Date:2020-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN31003191OtherMEDICARE B