Provider Demographics
NPI:1568867430
Name:ELLIS, SHANNON M (PTA)
Entity Type:Individual
Prefix:MRS
First Name:SHANNON
Middle Name:M
Last Name:ELLIS
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3576 PHOENIX COVE DR
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30506-4669
Mailing Address - Country:US
Mailing Address - Phone:574-286-2559
Mailing Address - Fax:
Practice Address - Street 1:5775 OLD WINDER HWY
Practice Address - Street 2:
Practice Address - City:BRASELTON
Practice Address - State:GA
Practice Address - Zip Code:30517-1603
Practice Address - Country:US
Practice Address - Phone:678-866-4104
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-11-04
Last Update Date:2014-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPTA002735225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant