Provider Demographics
NPI:1518523158
Name:GANNON, MARIA
Entity Type:Individual
Prefix:
First Name:MARIA
Middle Name:
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 1:4630 TWAIN ST
Mailing Address - Street 2:
Mailing Address - City:AMES
Mailing Address - State:IA
Mailing Address - Zip Code:50014-8127
Mailing Address - Country:US
Mailing Address - Phone:319-631-8993
Mailing Address - Fax:
Practice Address - Street 1:212 LAFAYETTE AVE
Practice Address - Street 2:
Practice Address - City:STORY CITY
Practice Address - State:IA
Practice Address - Zip Code:50248-1454
Practice Address - Country:US
Practice Address - Phone:515-733-4325
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-18
Last Update Date:2019-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2251G0304XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGeriatricsGroup - Single Specialty