Provider Demographics
NPI:1487043881
Name:MORTIMER, SHANNON (LAT, C)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:MORTIMER
Suffix:
Gender:F
Credentials:LAT, C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9634 W ROSEDALE AVE
Mailing Address - Street 2:
Mailing Address - City:WEST ALLIS
Mailing Address - State:WI
Mailing Address - Zip Code:53227-3332
Mailing Address - Country:US
Mailing Address - Phone:920-418-0460
Mailing Address - Fax:
Practice Address - Street 1:9634 W ROSEDALE AVE
Practice Address - Street 2:
Practice Address - City:WEST ALLIS
Practice Address - State:WI
Practice Address - Zip Code:53227-3332
Practice Address - Country:US
Practice Address - Phone:920-418-0460
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-01-22
Last Update Date:2015-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI585-0392255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer