MEDICARE: LAURA CANNISTRA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist	PT60237976	WA

General Provider Information

NPI Number	:	1154669356
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LAURA CANNISTRA

Provider Business Mailing Address
First Line	:	19401 40TH AVE W STE 330
Second Line	:
City	:	LYNNWOOD
State	:	WA
Zip	:	98036-5600
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	19401 40TH AVE W STE 330
Second Line	:
City	:	LYNNWOOD
State	:	WA
Zip	:	98036-5600
Country	:	US
Telephone Number	:	425-670-9987
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/22/2013
Last Update Date	:	01/22/2013

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1427488402 — JUSTIN HICKS
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Directions to “ LAURA CANNISTRA ” Practice Location

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