Provider Demographics
NPI:1285013300
Name:BROYLES, SHANNA
Entity Type:Individual
Prefix:
First Name:SHANNA
Middle Name:
Last Name:BROYLES
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 1:9000 S COUNTY ROAD 800 W
Mailing Address - Street 2:
Mailing Address - City:DALEVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47334-9420
Mailing Address - Country:US
Mailing Address - Phone:765-644-0500
Mailing Address - Fax:765-378-9019
Practice Address - Street 1:9000 S COUNTY ROAD 800 W
Practice Address - Street 2:
Practice Address - City:DALEVILLE
Practice Address - State:IN
Practice Address - Zip Code:47334-9420
Practice Address - Country:US
Practice Address - Phone:765-644-0500
Practice Address - Fax:765-378-9019
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-21
Last Update Date:2015-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN06002431A225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant