MEDICARE: KATHERINE ELLIOTT CANNON

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist	2305204298	VA

General Provider Information

NPI Number	:	1609853043
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KATHERINE ELLIOTT CANNON

Provider Business Mailing Address
First Line	:	1517 CARTER ST
Second Line	:
City	:	RICHMOND
State	:	VA
Zip	:	23220-6903
Country	:	US
Telephone Number	:	804-920-4277
Fax Number	:

Provider Business Practice Location Address
First Line	:	1465 JOHNSTON WILLIS DR
Second Line	:
City	:	NORTH CHESTERFIELD
State	:	VA
Zip	:	23235-4730
Country	:	US
Telephone Number	:	804-320-3668
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/28/2005
Last Update Date	:	09/23/2016

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