Provider Demographics
NPI:1679826564
Name:EBERT, SHAWNDA LUCIA (LAT, ATC)
Entity Type:Individual
Prefix:MRS
First Name:SHAWNDA
Middle Name:LUCIA
Last Name:EBERT
Suffix:
Gender:F
Credentials:LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:171 N KEENELAND DR
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:KY
Mailing Address - Zip Code:40475-8687
Mailing Address - Country:US
Mailing Address - Phone:859-797-1757
Mailing Address - Fax:
Practice Address - Street 1:171 N KEENELAND DR
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:KY
Practice Address - Zip Code:40475-8687
Practice Address - Country:US
Practice Address - Phone:859-797-1757
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-17
Last Update Date:2019-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY2255A2300X
KYAT7502255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer