=====================================================
General NPI Number Information
=====================================================
NPI Number | 1821989955
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | HAILEY LYNN CANNAN
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/15/2025
-----------------------------------------------------
Last Update Date | 07/15/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4650 SR-16
-----------------------------------------------------
City | ST. AUGUSTINE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32092
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-940-2193
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4825 AVENUE A
-----------------------------------------------------
City | ST AUGUSTINE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32095-6267
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 239-331-6899
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225200000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Assistant
-----------------------------------------------------
License Number | 32688
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------