Provider Demographics
NPI:1699469320
Name:KINNARD, CASSANDRA JEAN LYNN (LMT)
Entity type:Individual
Prefix:MISS
First Name:CASSANDRA
Middle Name:JEAN LYNN
Last Name:KINNARD
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:325 FOREST GROVE DR
Mailing Address - Street 2:
Mailing Address - City:PEWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53072-3894
Mailing Address - Country:US
Mailing Address - Phone:262-563-3701
Mailing Address - Fax:
Practice Address - Street 1:325 FOREST GROVE DR
Practice Address - Street 2:
Practice Address - City:PEWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53072-3894
Practice Address - Country:US
Practice Address - Phone:262-563-3701
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-06
Last Update Date:2024-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI17049-146225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist