Provider Demographics
NPI:1235306119
Name:ROBERTS, SHANNON (DC)
Entity Type:Individual
Prefix:DR
First Name:SHANNON
Middle Name:
Last Name:ROBERTS
Suffix:
Gender:F
Credentials:DC
Other - Prefix:DR
Other - First Name:SHANNON
Other - Middle Name:
Other - Last Name:MODDEJONGE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DC
Mailing Address - Street 1:3786 S EAST ST
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46227-1241
Mailing Address - Country:US
Mailing Address - Phone:317-791-1511
Mailing Address - Fax:317-791-1534
Practice Address - Street 1:3786 S EAST ST
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46227-1241
Practice Address - Country:US
Practice Address - Phone:317-791-1511
Practice Address - Fax:317-791-1534
Is Sole Proprietor?:No
Enumeration Date:2008-05-10
Last Update Date:2011-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX10800111N00000X
IN08002519A111N00000X
OH3943111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor