Provider Demographics
NPI:1316305006
Name:CANNIZZO, ZACHARY S (ATC, LAT)
Entity type:Individual
Prefix:
First Name:ZACHARY
Middle Name:S
Last Name:CANNIZZO
Suffix:
Gender:M
Credentials:ATC, LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3586 N FOREST RIDGE ST
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67205-4502
Mailing Address - Country:US
Mailing Address - Phone:785-307-0718
Mailing Address - Fax:
Practice Address - Street 1:1151 N ROCK RD
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67206-1262
Practice Address - Country:US
Practice Address - Phone:316-634-3400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-02-09
Last Update Date:2016-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS24-009132255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer