Provider Demographics
NPI:1396402855
Name:RUSSELL, SHANNON LYNN (DPT)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:LYNN
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5 BEVERLY CT
Mailing Address - Street 2:
Mailing Address - City:ROBBINSVILLE
Mailing Address - State:NJ
Mailing Address - Zip Code:08691-1332
Mailing Address - Country:US
Mailing Address - Phone:609-436-9089
Mailing Address - Fax:
Practice Address - Street 1:5 BEVERLY CT
Practice Address - Street 2:
Practice Address - City:ROBBINSVILLE
Practice Address - State:NJ
Practice Address - Zip Code:08691-1332
Practice Address - Country:US
Practice Address - Phone:609-436-9089
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-19
Last Update Date:2021-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA02049300225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist