Provider Demographics
NPI:1780037960
Name:CANNON, KELLI KAPRICE (PT)
Entity Type:Individual
Prefix:
First Name:KELLI
Middle Name:KAPRICE
Last Name:CANNON
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1121 CHANTELL ST
Mailing Address - Street 2:
Mailing Address - City:ENID
Mailing Address - State:OK
Mailing Address - Zip Code:73703-2940
Mailing Address - Country:US
Mailing Address - Phone:580-484-3059
Mailing Address - Fax:580-234-4237
Practice Address - Street 1:1121 CHANTELL ST
Practice Address - Street 2:
Practice Address - City:ENID
Practice Address - State:OK
Practice Address - Zip Code:73703-2940
Practice Address - Country:US
Practice Address - Phone:580-484-3059
Practice Address - Fax:580-234-4237
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-22
Last Update Date:2016-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1489225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist