Provider Demographics
NPI:1275739013
Name:STEPHEN, SHANNON (PTA)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:STEPHEN
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2111 BAINBRIDGE AVE
Mailing Address - Street 2:
Mailing Address - City:PONCA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:74604-2404
Mailing Address - Country:US
Mailing Address - Phone:580-765-0057
Mailing Address - Fax:
Practice Address - Street 1:521 MAIN ST
Practice Address - Street 2:
Practice Address - City:VAN BUREN
Practice Address - State:AR
Practice Address - Zip Code:72956-5109
Practice Address - Country:US
Practice Address - Phone:479-410-1740
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK619225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant