Provider Demographics
NPI:1093363442
Name:WAID, SHANNON (LMT, CST)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:WAID
Suffix:
Gender:F
Credentials:LMT, CST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:135 166TH ST NE
Mailing Address - Street 2:
Mailing Address - City:BRADENTON
Mailing Address - State:FL
Mailing Address - Zip Code:34212-5605
Mailing Address - Country:US
Mailing Address - Phone:720-325-8473
Mailing Address - Fax:
Practice Address - Street 1:9020 58TH DR E STE 101
Practice Address - Street 2:
Practice Address - City:BRADENTON
Practice Address - State:FL
Practice Address - Zip Code:34202-6107
Practice Address - Country:US
Practice Address - Phone:941-755-0406
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-29
Last Update Date:2019-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA86132172M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172M00000XOther Service ProvidersMechanotherapist