Provider Demographics
NPI:1740205129
Name:SHANNON, KARRIE A (PT)
Entity Type:Individual
Prefix:
First Name:KARRIE
Middle Name:A
Last Name:SHANNON
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 1:1257 FOXFIRE DR
Mailing Address - Street 2:
Mailing Address - City:PAINESVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:44077-5257
Mailing Address - Country:US
Mailing Address - Phone:440-974-2250
Mailing Address - Fax:
Practice Address - Street 1:35000 KAISER CT
Practice Address - Street 2:SUITE 301
Practice Address - City:WILLOUGHBY
Practice Address - State:OH
Practice Address - Zip Code:44094-3382
Practice Address - Country:US
Practice Address - Phone:440-951-6677
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPT 009156225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2622755Medicaid
OHSH4173642Medicare ID - Type UnspecifiedSHAKER
OHSH4173641Medicare ID - Type UnspecifiedWILLOUGHBY