Provider Demographics
NPI:1184653057
Name:TOMASULA, SHANNON (ATC)
Entity Type:Individual
Prefix:MS
First Name:SHANNON
Middle Name:
Last Name:TOMASULA
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 WILLOW ST
Mailing Address - Street 2:
Mailing Address - City:LAKEHURST
Mailing Address - State:NJ
Mailing Address - Zip Code:08733-2530
Mailing Address - Country:US
Mailing Address - Phone:732-657-3673
Mailing Address - Fax:
Practice Address - Street 1:30 CHURCH LN
Practice Address - Street 2:MANALAPAN HIGH SCHOOL
Practice Address - City:MANALAPAN
Practice Address - State:NJ
Practice Address - Zip Code:07726-3402
Practice Address - Country:US
Practice Address - Phone:732-792-7200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MT000986002255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer