Provider Demographics
NPI:1558360354
Name:WARE, SHENANDOAH LEE (PT)
Entity Type:Individual
Prefix:
First Name:SHENANDOAH
Middle Name:LEE
Last Name:WARE
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:SHAN
Other - Middle Name:LEE
Other - Last Name:WARE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:3700 HAINES RD N APT 8
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33704-1150
Mailing Address - Country:US
Mailing Address - Phone:870-577-3264
Mailing Address - Fax:
Practice Address - Street 1:3700 HAINES RD N APT 8
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33704-1150
Practice Address - Country:US
Practice Address - Phone:870-577-3264
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-14
Last Update Date:2022-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPT782225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR138734721Medicaid
AR5U357Medicare PIN