Provider Demographics
NPI:1942451356
Name:CANNON, NICOLE MARGARET (DPT)
Entity Type:Individual
Prefix:MS
First Name:NICOLE
Middle Name:MARGARET
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 1:2129 W OREGON AVE
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19145-4131
Mailing Address - Country:US
Mailing Address - Phone:215-336-6630
Mailing Address - Fax:215-336-3928
Practice Address - Street 1:2129 W OREGON AVE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19145-4131
Practice Address - Country:US
Practice Address - Phone:215-336-6630
Practice Address - Fax:215-336-3928
Is Sole Proprietor?:No
Enumeration Date:2008-10-03
Last Update Date:2008-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPT019539225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist