Provider Demographics
NPI:1326009119
Name:WALTERS, SHANNON RENAE (DC)
Entity Type:Individual
Prefix:DR
First Name:SHANNON
Middle Name:RENAE
Last Name:WALTERS
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:121 W KING ST
Mailing Address - Street 2:P.O. BOX 763
Mailing Address - City:EAST BERLIN
Mailing Address - State:PA
Mailing Address - Zip Code:17316-9728
Mailing Address - Country:US
Mailing Address - Phone:717-259-8056
Mailing Address - Fax:717-259-6774
Practice Address - Street 1:121 W KING ST
Practice Address - Street 2:
Practice Address - City:EAST BERLIN
Practice Address - State:PA
Practice Address - Zip Code:17316-9728
Practice Address - Country:US
Practice Address - Phone:717-259-8056
Practice Address - Fax:717-259-6774
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADC006278L111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA273643OtherMAMSI
PA2226775OtherUNITED HEALTHCARE
PA5990505OtherAETNA
PA8661359001OtherCIGNA
PA0761669OtherKEYSTONE HEALTH PLAN
PA03086800OtherCAPITAL BLUE CROSS
PAWA761669OtherHIGHMARK
PA03086800OtherCAPITAL BLUE CROSS
PA0761669OtherKEYSTONE HEALTH PLAN