Provider Demographics
NPI:1558820167
Name:SHIPP, JOHNNY
Entity Type:Individual
Prefix:
First Name:JOHNNY
Middle Name:
Last Name:SHIPP
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:RR 3 BOX 3624
Mailing Address - Street 2:
Mailing Address - City:THAYER
Mailing Address - State:MO
Mailing Address - Zip Code:65791-9309
Mailing Address - Country:US
Mailing Address - Phone:573-476-7780
Mailing Address - Fax:
Practice Address - Street 1:600 EAST STADIUM BOULEVARD
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65211-0001
Practice Address - Country:US
Practice Address - Phone:573-476-7780
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-14
Last Update Date:2019-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer