Provider Demographics
NPI:1730319104
Name:KANNER, KATHRYN (MD)
Entity Type:Individual
Prefix:DR
First Name:KATHRYN
Middle Name:
Last Name:KANNER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1430 E MISSOURI AVE STE B100
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85014-2480
Mailing Address - Country:US
Mailing Address - Phone:602-883-2318
Mailing Address - Fax:877-992-9257
Practice Address - Street 1:1430 E MISSOURI AVE STE B100
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85014-2480
Practice Address - Country:US
Practice Address - Phone:602-883-2318
Practice Address - Fax:877-992-9257
Is Sole Proprietor?:No
Enumeration Date:2009-07-20
Last Update Date:2022-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ450452084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ624357Medicaid