Provider Demographics
NPI:1619561909
Name:MCILWAINE, SHANNON NICOLE
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:NICOLE
Last Name:MCILWAINE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2333 TREMONT PL
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80205-3135
Mailing Address - Country:US
Mailing Address - Phone:813-892-1152
Mailing Address - Fax:
Practice Address - Street 1:13710 E RICE PL STE 100
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:CO
Practice Address - Zip Code:80015-1075
Practice Address - Country:US
Practice Address - Phone:813-892-1152
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-26
Last Update Date:2021-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist