Provider Demographics
NPI:1982176954
Name:CUNNINGHAM, KATIE
Entity type:Individual
Prefix:
First Name:KATIE
Middle Name:
Last Name:CUNNINGHAM
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 1:36648 COUNTY ROAD 39
Mailing Address - Street 2:
Mailing Address - City:EATON
Mailing Address - State:CO
Mailing Address - Zip Code:80615-9011
Mailing Address - Country:US
Mailing Address - Phone:970-590-1919
Mailing Address - Fax:
Practice Address - Street 1:100 LINDSEY LN STE A
Practice Address - Street 2:
Practice Address - City:SAINT MARYS
Practice Address - State:GA
Practice Address - Zip Code:31558-1727
Practice Address - Country:US
Practice Address - Phone:912-729-1333
Practice Address - Fax:912-729-5299
Is Sole Proprietor?:No
Enumeration Date:2019-01-01
Last Update Date:2021-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225100000X
GACP004671T225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist