Provider Demographics
NPI:1891354528
Name:CANNON, KRISTEN (DPT)
Entity Type:Individual
Prefix:
First Name:KRISTEN
Middle Name:
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 1:2421 FAIRWAY OAKS CT
Mailing Address - Street 2:
Mailing Address - City:HAMPSTEAD
Mailing Address - State:MD
Mailing Address - Zip Code:21074-1350
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:10803 FALLS RD STE 2100
Practice Address - Street 2:
Practice Address - City:LUTHERVILLE
Practice Address - State:MD
Practice Address - Zip Code:21093-4502
Practice Address - Country:US
Practice Address - Phone:410-583-2665
Practice Address - Fax:410-847-3838
Is Sole Proprietor?:No
Enumeration Date:2019-06-06
Last Update Date:2019-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD27461225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist