Provider Demographics
NPI:1326701228
Name:YOUNG, SHANIA MARIE (LAT, ATC)
Entity Type:Individual
Prefix:
First Name:SHANIA
Middle Name:MARIE
Last Name:YOUNG
Suffix:
Gender:F
Credentials:LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:310 BARLEY CIR
Mailing Address - Street 2:
Mailing Address - City:CRITTENDEN
Mailing Address - State:KY
Mailing Address - Zip Code:41030-8720
Mailing Address - Country:US
Mailing Address - Phone:859-409-2152
Mailing Address - Fax:
Practice Address - Street 1:830 THOMAS MORE PKWY
Practice Address - Street 2:
Practice Address - City:CRESTVIEW HILLS
Practice Address - State:KY
Practice Address - Zip Code:41017-5102
Practice Address - Country:US
Practice Address - Phone:859-409-2152
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-18
Last Update Date:2021-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYAT19572255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
KYAT1957OtherKENTUCKY BOARD OF MEDICAL LICENSURE
KY2000042331OtherBOARD OF CERTIFICATION FOR THE ATHLETIC TRAINER