Provider Demographics
NPI:1578842316
Name:CANNON, BETHANY JOY (DC)
Entity Type:Individual
Prefix:DR
First Name:BETHANY
Middle Name:JOY
Last Name:CANNON
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:BETHANY
Other - Middle Name:JOY
Other - Last Name:FORSYTH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DC
Mailing Address - Street 1:6303 CENTER ST.
Mailing Address - Street 2:SUITE 103
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68106-3456
Mailing Address - Country:US
Mailing Address - Phone:402-933-1933
Mailing Address - Fax:402-504-3264
Practice Address - Street 1:6303 CENTER ST.
Practice Address - Street 2:SUITE 103
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68106-3456
Practice Address - Country:US
Practice Address - Phone:402-933-1933
Practice Address - Fax:402-504-3264
Is Sole Proprietor?:No
Enumeration Date:2011-08-10
Last Update Date:2012-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE1680111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE1002582600Medicaid
NE1002582600Medicaid