Provider Demographics
NPI:1093866196
Name:PENA-BRANSTNER, CARMEN SHANNON (PT)
Entity Type:Individual
Prefix:
First Name:CARMEN
Middle Name:SHANNON
Last Name:PENA-BRANSTNER
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:227 FERGUSON ST
Mailing Address - Street 2:
Mailing Address - City:LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48912-2211
Mailing Address - Country:US
Mailing Address - Phone:517-482-6809
Mailing Address - Fax:
Practice Address - Street 1:1660 HASLETT RD
Practice Address - Street 2:SUITE 4
Practice Address - City:HASLETT
Practice Address - State:MI
Practice Address - Zip Code:48840-8469
Practice Address - Country:US
Practice Address - Phone:517-339-4050
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501012653225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist