Provider Demographics
NPI:1710904602
Name:CANNON, TRACEY MICHELLE
Entity Type:Individual
Prefix:
First Name:TRACEY
Middle Name:MICHELLE
Last Name:CANNON
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 1:626 TRAIL AVE
Mailing Address - Street 2:
Mailing Address - City:FREDERICK
Mailing Address - State:MD
Mailing Address - Zip Code:21701-4934
Mailing Address - Country:US
Mailing Address - Phone:301-662-1997
Mailing Address - Fax:
Practice Address - Street 1:626 TRAIL AVE
Practice Address - Street 2:
Practice Address - City:FREDERICK
Practice Address - State:MD
Practice Address - Zip Code:21701-4934
Practice Address - Country:US
Practice Address - Phone:301-662-1997
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-16
Last Update Date:2008-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD19215225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDKBC4HO-61628901OtherBC/BS
MDS404-0008OtherCAREFIRST
MD167ME433Medicare PIN
DCG00930-010218H30Medicare PIN