Provider Demographics
NPI:1619095346
Name:SHOCKEY, SHAWNA LEA (MPT)
Entity Type:Individual
Prefix:
First Name:SHAWNA
Middle Name:LEA
Last Name:SHOCKEY
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5725 OLEANDER DR STE A4
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28403-4749
Mailing Address - Country:US
Mailing Address - Phone:910-392-2240
Mailing Address - Fax:910-392-2242
Practice Address - Street 1:3015 ENTERPRISE DR
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28405-2116
Practice Address - Country:US
Practice Address - Phone:877-787-3430
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-27
Last Update Date:2022-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY003960225100000X
OH0091032251P0200X
NCP11019225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
No2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH46-5304557OtherIRS EIN