Provider Demographics
NPI:1790020949
Name:KENISON, SHELBY N (ATC)
Entity Type:Individual
Prefix:
First Name:SHELBY
Middle Name:N
Last Name:KENISON
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:SHELBY
Other - Middle Name:N
Other - Last Name:VIETZE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:ATC
Mailing Address - Street 1:28675 740TH AVE
Mailing Address - Street 2:
Mailing Address - City:CLARKS GROVE
Mailing Address - State:MN
Mailing Address - Zip Code:56016-4041
Mailing Address - Country:US
Mailing Address - Phone:507-213-3487
Mailing Address - Fax:
Practice Address - Street 1:28675 740TH AVE
Practice Address - Street 2:
Practice Address - City:CLARKS GROVE
Practice Address - State:MN
Practice Address - Zip Code:56016-4041
Practice Address - Country:US
Practice Address - Phone:507-213-3487
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-11-29
Last Update Date:2020-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN23062081S0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2081S0010XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationSports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1790020949OtherNPI