Provider Demographics
NPI:1679617435
Name:GARDNER, SHELLY P (PT)
Entity Type:Individual
Prefix:
First Name:SHELLY
Middle Name:P
Last Name:GARDNER
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 1:1080 NEAL ST
Mailing Address - Street 2:SUITE 300
Mailing Address - City:COOKEVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:38501
Mailing Address - Country:US
Mailing Address - Phone:931-372-2567
Mailing Address - Fax:931-372-2572
Practice Address - Street 1:1080 NEAL ST
Practice Address - Street 2:SUITE 300
Practice Address - City:COOKEVILLE
Practice Address - State:TN
Practice Address - Zip Code:38501
Practice Address - Country:US
Practice Address - Phone:931-372-2567
Practice Address - Fax:931-372-2572
Is Sole Proprietor?:No
Enumeration Date:2007-02-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNPT1594225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist