Healthcare Provider Details

I. General information

NPI: 1700216181
Provider Name (Legal Business Name): TIA KINCANNON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/20/2013
Last Update Date: 11/20/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2208 N LOOP 250 W
MIDLAND TX
79707-6011
US

IV. Provider business mailing address

2208 N LOOP 250 W,
MIDLAND TX
79707
US

V. Phone/Fax

Practice location:
  • Phone: 432-689-9898
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number2096326
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: