Provider Demographics
NPI:1417236589
Name:MARSO, SHANNON C (PTA)
Entity Type:Individual
Prefix:MRS
First Name:SHANNON
Middle Name:C
Last Name:MARSO
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 1:2455 PECAN AVE.
Mailing Address - Street 2:
Mailing Address - City:GUTHRIE CENTER
Mailing Address - State:IA
Mailing Address - Zip Code:50115
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:508 2ND ST NE
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:IA
Practice Address - Zip Code:50530-7530
Practice Address - Country:US
Practice Address - Phone:515-547-2288
Practice Address - Fax:515-547-2287
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-08
Last Update Date:2016-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA001456314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility