Provider Demographics
NPI:1528484870
Name:CANNON, KELLIE C (DPT)
Entity type:Individual
Prefix:
First Name:KELLIE
Middle Name:C
Last Name:CANNON
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 RIVER RD
Mailing Address - Street 2:
Mailing Address - City:EUGENE
Mailing Address - State:OR
Mailing Address - Zip Code:97404
Mailing Address - Country:US
Mailing Address - Phone:541-689-0935
Mailing Address - Fax:541-461-6884
Practice Address - Street 1:1000 RIVER RD
Practice Address - Street 2:
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97404
Practice Address - Country:US
Practice Address - Phone:541-689-0935
Practice Address - Fax:541-461-6884
Is Sole Proprietor?:No
Enumeration Date:2014-03-11
Last Update Date:2025-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR60483225100000X, 2251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist