Provider Demographics
NPI:1497265557
Name:SHANER, KELLY (PT)
Entity Type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:
Last Name:SHANER
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11 N BROAD ST
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:VA
Mailing Address - Zip Code:24153-3735
Mailing Address - Country:US
Mailing Address - Phone:540-389-6305
Mailing Address - Fax:
Practice Address - Street 1:11 N BROAD ST
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:VA
Practice Address - Zip Code:24153-3735
Practice Address - Country:US
Practice Address - Phone:540-389-6305
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-03
Last Update Date:2017-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305005453225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist