Provider Demographics
NPI:1225363484
Name:PONCE, SHANNI (PT)
Entity Type:Individual
Prefix:
First Name:SHANNI
Middle Name:
Last Name:PONCE
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 1:501 S AUSTIN AVE UNIT 1310
Mailing Address - Street 2:
Mailing Address - City:GEORGETOWN
Mailing Address - State:TX
Mailing Address - Zip Code:78626-5639
Mailing Address - Country:US
Mailing Address - Phone:512-864-6052
Mailing Address - Fax:512-869-8157
Practice Address - Street 1:501 S AUSTIN AVE UNIT 1310
Practice Address - Street 2:
Practice Address - City:GEORGETOWN
Practice Address - State:TX
Practice Address - Zip Code:78626-5639
Practice Address - Country:US
Practice Address - Phone:512-864-6050
Practice Address - Fax:512-869-8157
Is Sole Proprietor?:No
Enumeration Date:2009-10-06
Last Update Date:2009-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1073989174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1073989OtherPHYSICAL THERAPY LICENSE