Provider Demographics
NPI:1629312319
Name:POCKETTE, SHANNON (PTA)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:POCKETTE
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 1:700 FRIENDLY RD
Mailing Address - Street 2:
Mailing Address - City:MOREHEAD CITY
Mailing Address - State:NC
Mailing Address - Zip Code:28557-6243
Mailing Address - Country:US
Mailing Address - Phone:252-646-8790
Mailing Address - Fax:
Practice Address - Street 1:700 FRIENDLY RD
Practice Address - Street 2:
Practice Address - City:MOREHEAD CITY
Practice Address - State:NC
Practice Address - Zip Code:28557-6243
Practice Address - Country:US
Practice Address - Phone:252-646-8790
Practice Address - Fax:252-240-3882
Is Sole Proprietor?:No
Enumeration Date:2012-11-19
Last Update Date:2023-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCA2129225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant