Provider Demographics
NPI:1376773929
Name:SANTIAGO, SHANNON MICHELLE (PTA)
Entity Type:Individual
Prefix:MRS
First Name:SHANNON
Middle Name:MICHELLE
Last Name:SANTIAGO
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:PO BOX 353306
Mailing Address - Street 2:
Mailing Address - City:PALM COAST
Mailing Address - State:FL
Mailing Address - Zip Code:32135-3306
Mailing Address - Country:US
Mailing Address - Phone:386-986-8897
Mailing Address - Fax:
Practice Address - Street 1:170 N CENTER ST
Practice Address - Street 2:
Practice Address - City:ORMOND BEACH
Practice Address - State:FL
Practice Address - Zip Code:32174-5186
Practice Address - Country:US
Practice Address - Phone:386-944-4938
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-16
Last Update Date:2009-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL21320225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant