Provider Demographics
NPI:1083846372
Name:SMITHEY, SHANNON E (PT)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:E
Last Name:SMITHEY
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:SHANNON
Other - Middle Name:E
Other - Last Name:FOO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:815 SIMMONS ST
Mailing Address - Street 2:
Mailing Address - City:ENTERPRISE
Mailing Address - State:AL
Mailing Address - Zip Code:36330-2818
Mailing Address - Country:US
Mailing Address - Phone:800-261-7193
Mailing Address - Fax:334-255-7710
Practice Address - Street 1:301 ANDREWS AVE. LYSTER ARMY HEALTH CLINIC
Practice Address - Street 2:
Practice Address - City:FORT RUCKER
Practice Address - State:AL
Practice Address - Zip Code:36362-5333
Practice Address - Country:US
Practice Address - Phone:800-261-7193
Practice Address - Fax:334-255-7710
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-20
Last Update Date:2017-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0010988225100000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program