Healthcare Provider Details

I. General information

NPI: 1821989955
Provider Name (Legal Business Name): HAILEY LYNN CANNAN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/15/2025
Last Update Date: 07/15/2025
Certification Date: 06/29/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4650 SR-16
ST. AUGUSTINE FL
32092
US

IV. Provider business mailing address

4825 AVENUE A
ST AUGUSTINE FL
32095-6267
US

V. Phone/Fax

Practice location:
  • Phone: 904-940-2193
  • Fax:
Mailing address:
  • Phone: 239-331-6899
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number32688
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: