MEDICARE: MS. NICOLE MARGARET CANNON DPT

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	PT019539	PA

General Provider Information

NPI Number	:	1942451356
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. NICOLE MARGARET CANNON DPT

Provider Business Mailing Address
First Line	:	2129 W OREGON AVE
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19145-4131
Country	:	US
Telephone Number	:	215-336-6630
Fax Number	:	215-336-3928

Provider Business Practice Location Address
First Line	:	2129 W OREGON AVE
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19145-4131
Country	:	US
Telephone Number	:	215-336-6630
Fax Number	:	215-336-3928

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

Provider Enumeration Date	:	10/03/2008
Last Update Date	:	10/03/2008

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