Provider Demographics
NPI:1790963155
Name:SHIPLEY, MARY KRISTEN (PT)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:KRISTEN
Last Name:SHIPLEY
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:KRISTEN
Other - Middle Name:SHIPLEY
Other - Last Name:MINOR
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PT
Mailing Address - Street 1:3200 NORTHLINE AVE STE 160
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27408-7613
Mailing Address - Country:US
Mailing Address - Phone:336-545-5000
Mailing Address - Fax:
Practice Address - Street 1:3200 NORTHLINE AVE STE 160
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27408-7613
Practice Address - Country:US
Practice Address - Phone:336-545-5000
Practice Address - Fax:336-545-5020
Is Sole Proprietor?:No
Enumeration Date:2008-02-07
Last Update Date:2020-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC11480225100000X, 2251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCQ36607BOtherMEDICARE
NC1790963155Medicaid
NCQ36607AOtherMEDICARE PTAN