Provider Demographics
NPI:1497839765
Name:CANNON, KETRINA (OT)
Entity Type:Individual
Prefix:
First Name:KETRINA
Middle Name:
Last Name:CANNON
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1054 HIGHLAND COVE PL
Mailing Address - Street 2:
Mailing Address - City:RIDGELAND
Mailing Address - State:MS
Mailing Address - Zip Code:39157-1523
Mailing Address - Country:US
Mailing Address - Phone:601-636-6019
Mailing Address - Fax:601-661-8457
Practice Address - Street 1:110 HOLT COLLIER DRIVE
Practice Address - Street 2:
Practice Address - City:VICKSBURG
Practice Address - State:MS
Practice Address - Zip Code:39180
Practice Address - Country:US
Practice Address - Phone:601-636-6019
Practice Address - Fax:601-661-8457
Is Sole Proprietor?:No
Enumeration Date:2006-10-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSOT2017225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist