Provider Demographics
NPI:1790092658
Name:CANNON, CASEY E (DPT)
Entity Type:Individual
Prefix:
First Name:CASEY
Middle Name:E
Last Name:CANNON
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10104 WOODLAND BIRCH CV
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:TN
Mailing Address - Zip Code:38002-3950
Mailing Address - Country:US
Mailing Address - Phone:901-355-6406
Mailing Address - Fax:
Practice Address - Street 1:8059 STAGE HILLS BLVD
Practice Address - Street 2:SUITE 104
Practice Address - City:BARTLETT
Practice Address - State:TN
Practice Address - Zip Code:38133-4047
Practice Address - Country:US
Practice Address - Phone:901-383-4515
Practice Address - Fax:901-383-4505
Is Sole Proprietor?:No
Enumeration Date:2010-09-13
Last Update Date:2014-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN8743225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN373021Medicare PIN
TN1036I58828Medicare PIN