Healthcare Provider Details

I. General information

NPI: 1447920699
Provider Name (Legal Business Name): KELLEN CANNON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/19/2021
Last Update Date: 09/22/2025
Certification Date: 09/22/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9 LEE AIRPARK DR STE 400
EDGEWATER MD
21037-1229
US

IV. Provider business mailing address

2001 BUTTERFIELD RD STE 1600
DOWNERS GROVE IL
60515-1211
US

V. Phone/Fax

Practice location:
  • Phone: 443-607-1469
  • Fax:
Mailing address:
  • Phone: 866-370-8206
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number2305214662
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: