Provider Demographics
NPI:1962113803
Name:KANNE, JO ELLEN SULLIVAN
Entity type:Individual
Prefix:
First Name:JO ELLEN
Middle Name:SULLIVAN
Last Name:KANNE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3542 GIRARD AVE N
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55412-2418
Mailing Address - Country:US
Mailing Address - Phone:612-205-3079
Mailing Address - Fax:
Practice Address - Street 1:5747 W BROADWAY AVE STE 112
Practice Address - Street 2:
Practice Address - City:CRYSTAL
Practice Address - State:MN
Practice Address - Zip Code:55428-3881
Practice Address - Country:US
Practice Address - Phone:612-205-3079
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-12-12
Last Update Date:2022-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist