Provider Demographics
NPI:1689869174
Name:CONERLY, SHAVON A (PT)
Entity Type:Individual
Prefix:
First Name:SHAVON
Middle Name:A
Last Name:CONERLY
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 1:800 CRESCENT CENTRE DR STE 300
Mailing Address - Street 2:
Mailing Address - City:FRANKLIN
Mailing Address - State:TN
Mailing Address - Zip Code:37067-7285
Mailing Address - Country:US
Mailing Address - Phone:615-656-0379
Mailing Address - Fax:615-221-9054
Practice Address - Street 1:950 E COUNTY LINE RD STE D
Practice Address - Street 2:
Practice Address - City:RIDGELAND
Practice Address - State:MS
Practice Address - Zip Code:39157-1928
Practice Address - Country:US
Practice Address - Phone:601-899-0002
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-09-08
Last Update Date:2022-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALPTH5127225100000X
MSPT4722225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL515 96290OtherBLUE CROSS AND BLUE SHIELD
AL107890Medicaid