MEDICARE: MICHELLE I CANNON PT

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	PT12731	FL

General Provider Information

NPI Number	:	1629418496
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MICHELLE I CANNON PT

Provider Business Mailing Address
First Line	:	1847 VISTA LAKES DR
Second Line	:
City	:	FLEMING ISLAND
State	:	FL
Zip	:	32003-7301
Country	:	US
Telephone Number	:	904-703-8030
Fax Number	:

Provider Business Practice Location Address
First Line	:	1847 VISTA LAKES DR
Second Line	:
City	:	FLEMING ISLAND
State	:	FL
Zip	:	32003-7301
Country	:	US
Telephone Number	:	904-703-8030
Fax Number	:

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

Provider Enumeration Date	:	06/26/2013
Last Update Date	:	06/26/2013

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Directions to “ MICHELLE I CANNON PT” Practice Location

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