Healthcare Provider Details

I. General information

NPI: 1689258675
Provider Name (Legal Business Name): ADRIA CANNON STUDENT, PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/06/2021
Last Update Date: 06/05/2026
Certification Date: 06/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2209 N 30TH ST STE 5
TACOMA WA
98403-3352
US

IV. Provider business mailing address

5620 112TH ST E STE 215
PUYALLUP WA
98373-3206
US

V. Phone/Fax

Practice location:
  • Phone: 253-446-7176
  • Fax:
Mailing address:
  • Phone: 206-708-3850
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number60567605
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberMHCA.MC.61309127
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: