Provider Demographics
NPI:1497235584
Name:GANNON, ABIGAIL N
Entity Type:Individual
Prefix:
First Name:ABIGAIL
Middle Name:N
Last Name:GANNON
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 1:392 BUTTERNUT DR
Mailing Address - Street 2:
Mailing Address - City:NORTH KINGSTOWN
Mailing Address - State:RI
Mailing Address - Zip Code:02852-6951
Mailing Address - Country:US
Mailing Address - Phone:401-486-1692
Mailing Address - Fax:
Practice Address - Street 1:626 PARK AVE
Practice Address - Street 2:
Practice Address - City:CRANSTON
Practice Address - State:RI
Practice Address - Zip Code:02910-2154
Practice Address - Country:US
Practice Address - Phone:401-270-9991
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-17
Last Update Date:2018-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RI235Z00000X235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty