Provider Demographics
NPI:1235333782
Name:WALKER, SHANNON LYNN
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:LYNN
Last Name:WALKER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24 HAMMOND STE C
Mailing Address - Street 2:
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92618-1680
Mailing Address - Country:US
Mailing Address - Phone:949-770-6022
Mailing Address - Fax:949-770-7084
Practice Address - Street 1:101 E LINCOLN AVE STE 111
Practice Address - Street 2:
Practice Address - City:ANAHEIM
Practice Address - State:CA
Practice Address - Zip Code:92805-3203
Practice Address - Country:US
Practice Address - Phone:714-774-6502
Practice Address - Fax:714-774-0860
Is Sole Proprietor?:No
Enumeration Date:2007-06-11
Last Update Date:2010-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT23556225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAWPT23556CMedicare UPIN