Provider Demographics
NPI:1376181354
Name:SHANK, KATHERINE (MAT, LAT, ATC)
Entity Type:Individual
Prefix:
First Name:KATHERINE
Middle Name:
Last Name:SHANK
Suffix:
Gender:F
Credentials:MAT, LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:45 HOLLY PARK LN APT 211
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:VA
Mailing Address - Zip Code:24450-3755
Mailing Address - Country:US
Mailing Address - Phone:269-759-4262
Mailing Address - Fax:
Practice Address - Street 1:204 W WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:VA
Practice Address - Zip Code:24450-2554
Practice Address - Country:US
Practice Address - Phone:540-458-8166
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-12-20
Last Update Date:2019-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA01260027052255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer