Basic Information
| Provider Information | |||||||||
| NPI: | 1114306974 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BANNON | ||||||||
| FirstName: | KATHERINE | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | DPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 600 | ||||||||
| Address2: | |||||||||
| City: | TUBA CITY | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 860450600 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9282832501 | ||||||||
| FaxNumber: | 9282832677 | ||||||||
| Practice Location | |||||||||
| Address1: | 167 N. MAIN STREET | ||||||||
| Address2: | |||||||||
| City: | TUBA CITY | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 860450600 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9282832501 | ||||||||
| FaxNumber: | 9282832677 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/27/2015 | ||||||||
| LastUpdateDate: | 05/27/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | J10002847 | DE | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.