Provider Demographics
NPI:1205365319
Name:SMITH, SHANNON RENEE (PTA, ATC)
Entity Type:Individual
Prefix:MRS
First Name:SHANNON
Middle Name:RENEE
Last Name:SMITH
Suffix:
Gender:F
Credentials:PTA, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:679 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:AR
Mailing Address - Zip Code:72576-9451
Mailing Address - Country:US
Mailing Address - Phone:870-895-6006
Mailing Address - Fax:870-895-2626
Practice Address - Street 1:679 N MAIN ST
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:AR
Practice Address - Zip Code:72576-9451
Practice Address - Country:US
Practice Address - Phone:870-895-6006
Practice Address - Fax:870-895-2626
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-12
Last Update Date:2017-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARAT3122255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer