Provider Demographics
NPI:1548737117
Name:LAFOUNTAIN, SHANNON MARIE (LPTA)
Entity Type:Individual
Prefix:MS
First Name:SHANNON
Middle Name:MARIE
Last Name:LAFOUNTAIN
Suffix:
Gender:F
Credentials:LPTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6065 OAK GROVE LOOP
Mailing Address - Street 2:
Mailing Address - City:AMELIA COURT HOUSE
Mailing Address - State:VA
Mailing Address - Zip Code:23002-3543
Mailing Address - Country:US
Mailing Address - Phone:804-467-1971
Mailing Address - Fax:
Practice Address - Street 1:8830 VIRGINIA ST
Practice Address - Street 2:
Practice Address - City:AMELIA COURT HOUSE
Practice Address - State:VA
Practice Address - Zip Code:23002-4826
Practice Address - Country:US
Practice Address - Phone:804-561-1617
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-31
Last Update Date:2018-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2306001077225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant