Provider Demographics
NPI:1801855440
Name:CAMPBELL, SHANNON D (ATC/L)
Entity Type:Individual
Prefix:MR
First Name:SHANNON
Middle Name:D
Last Name:CAMPBELL
Suffix:
Gender:M
Credentials:ATC/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:330 N GRANT ST
Mailing Address - Street 2:
Mailing Address - City:MOSCOW
Mailing Address - State:ID
Mailing Address - Zip Code:83843-3674
Mailing Address - Country:US
Mailing Address - Phone:208-882-3239
Mailing Address - Fax:
Practice Address - Street 1:1114 9TH AVE
Practice Address - Street 2:
Practice Address - City:LEWISTON
Practice Address - State:ID
Practice Address - Zip Code:83501-2659
Practice Address - Country:US
Practice Address - Phone:208-748-3102
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDAT-0672255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer