Basic Information
| Provider Information | |||||||||
| NPI: | 1790834257 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CRANNELL | ||||||||
| FirstName: | JESSICA | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | MPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 402 MOHAWK ST | ||||||||
| Address2: | |||||||||
| City: | HERKIMER | ||||||||
| State: | NY | ||||||||
| PostalCode: | 133502217 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3157170020 | ||||||||
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| Practice Location | |||||||||
| Address1: | 402 MOHAWK ST | ||||||||
| Address2: | |||||||||
| City: | HERKIMER | ||||||||
| State: | NY | ||||||||
| PostalCode: | 133502217 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3157170020 | ||||||||
| FaxNumber: | 3157170024 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/10/2007 | ||||||||
| LastUpdateDate: | 09/13/2007 | ||||||||
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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 | 027294 | NY | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 11492114 | 01 | NY | CAQH | OTHER | 02673898 | 05 | NY | MEDICAID |