Provider Demographics
NPI:1972561470
Name:CANNON, KAYE B (OTRL CHT)
Entity Type:Individual
Prefix:MRS
First Name:KAYE
Middle Name:B
Last Name:CANNON
Suffix:
Gender:F
Credentials:OTRL CHT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1743 CLIFF GOOKIN BLVD
Mailing Address - Street 2:
Mailing Address - City:TUPELO
Mailing Address - State:MS
Mailing Address - Zip Code:38801-6723
Mailing Address - Country:US
Mailing Address - Phone:662-680-5216
Mailing Address - Fax:662-680-5217
Practice Address - Street 1:1743 CLIFF GOOKIN BLVD
Practice Address - Street 2:
Practice Address - City:TUPELO
Practice Address - State:MS
Practice Address - Zip Code:38801-6723
Practice Address - Country:US
Practice Address - Phone:662-680-5216
Practice Address - Fax:662-680-5217
Is Sole Proprietor?:No
Enumeration Date:2006-05-03
Last Update Date:2019-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSOTO912225XH1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XH1200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistHand
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09788312Medicaid
MS09788312Medicaid