Provider Demographics
NPI:1578734067
Name:SHANK, CONNIE (PT)
Entity Type:Individual
Prefix:
First Name:CONNIE
Middle Name:
Last Name:SHANK
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 1:6264 AVENTURA DR
Mailing Address - Street 2:
Mailing Address - City:SARASOTA
Mailing Address - State:FL
Mailing Address - Zip Code:34241-9446
Mailing Address - Country:US
Mailing Address - Phone:941-539-4964
Mailing Address - Fax:
Practice Address - Street 1:5230 KINGS MILLS RD
Practice Address - Street 2:
Practice Address - City:MASON
Practice Address - State:OH
Practice Address - Zip Code:45040-2319
Practice Address - Country:US
Practice Address - Phone:513-398-2000
Practice Address - Fax:513-332-9098
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-12
Last Update Date:2019-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH4294225100000X
FL3747A0650X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist