Provider Demographics
NPI:1467531202
Name:MILLINER, SHANNON BULLOCK (MPT)
Entity Type:Individual
Prefix:MRS
First Name:SHANNON
Middle Name:BULLOCK
Last Name:MILLINER
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7506 WARRENTON HILL CT
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40291-6716
Mailing Address - Country:US
Mailing Address - Phone:502-262-5710
Mailing Address - Fax:502-762-9250
Practice Address - Street 1:982 EASTERN PKWY
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40217-1566
Practice Address - Country:US
Practice Address - Phone:502-635-6397
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-03
Last Update Date:2020-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY004010225100000X
IN05007935A2251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics