Provider Demographics
NPI:1639147267
Name:PIERCE, SHANTELLE LEA (MPT)
Entity Type:Individual
Prefix:
First Name:SHANTELLE
Middle Name:LEA
Last Name:PIERCE
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:PO BOX 1314
Mailing Address - Street 2:
Mailing Address - City:FLORA VISTA
Mailing Address - State:NM
Mailing Address - Zip Code:87415-1314
Mailing Address - Country:US
Mailing Address - Phone:505-486-1750
Mailing Address - Fax:
Practice Address - Street 1:4310 LOWER HONOAPIILANI RD
Practice Address - Street 2:#110
Practice Address - City:LAHAINA
Practice Address - State:HI
Practice Address - Zip Code:96761-9246
Practice Address - Country:US
Practice Address - Phone:808-669-0078
Practice Address - Fax:808-669-0178
Is Sole Proprietor?:No
Enumeration Date:2006-03-09
Last Update Date:2013-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI3573225100000X
NM2333225100000X
CO0011896225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist