Provider Demographics
NPI:1710452651
Name:HERNDON, SHELBY LEA
Entity Type:Individual
Prefix:
First Name:SHELBY
Middle Name:LEA
Last Name:HERNDON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17310 BROOK RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:WAMEGO
Mailing Address - State:KS
Mailing Address - Zip Code:66547-7018
Mailing Address - Country:US
Mailing Address - Phone:785-545-7055
Mailing Address - Fax:
Practice Address - Street 1:1620 CHARLES PL
Practice Address - Street 2:
Practice Address - City:MANHATTAN
Practice Address - State:KS
Practice Address - Zip Code:66502-2750
Practice Address - Country:US
Practice Address - Phone:785-775-1444
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-08
Last Update Date:2024-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS14-03379225200000X
MO2018029310225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant