Provider Demographics
NPI:1124578695
Name:ESTES, SHANNON
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:ESTES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:800 W UNIVERSITY AVE
Mailing Address - Street 2:
Mailing Address - City:FLAGSTAFF
Mailing Address - State:AZ
Mailing Address - Zip Code:86001-7103
Mailing Address - Country:US
Mailing Address - Phone:928-779-6931
Mailing Address - Fax:
Practice Address - Street 1:800 W UNIVERSITY AVE
Practice Address - Street 2:
Practice Address - City:FLAGSTAFF
Practice Address - State:AZ
Practice Address - Zip Code:86001-7103
Practice Address - Country:US
Practice Address - Phone:928-779-6931
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-10-09
Last Update Date:2016-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ5280225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist