Provider Demographics
NPI:1164810339
Name:SHANNON, DEVIN MICHAEL (ATC)
Entity Type:Individual
Prefix:
First Name:DEVIN
Middle Name:MICHAEL
Last Name:SHANNON
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2015 NASH DR
Mailing Address - Street 2:
Mailing Address - City:DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50314-2050
Mailing Address - Country:US
Mailing Address - Phone:515-210-0822
Mailing Address - Fax:
Practice Address - Street 1:2015 NASH DR
Practice Address - Street 2:
Practice Address - City:DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50314-2050
Practice Address - Country:US
Practice Address - Phone:515-210-0822
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-12-22
Last Update Date:2014-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL096.0037842255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer