Provider Demographics
NPI:1831138387
Name:CAMPBELL, SHANI DEVON (PT)
Entity Type:Individual
Prefix:MS
First Name:SHANI
Middle Name:DEVON
Last Name:CAMPBELL
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:PO BOX 739
Mailing Address - Street 2:
Mailing Address - City:DOVER
Mailing Address - State:TN
Mailing Address - Zip Code:37058-0739
Mailing Address - Country:US
Mailing Address - Phone:731-641-8111
Mailing Address - Fax:731-641-8110
Practice Address - Street 1:109 COMMERCE ST
Practice Address - Street 2:
Practice Address - City:PARIS
Practice Address - State:TN
Practice Address - Zip Code:38242-4917
Practice Address - Country:US
Practice Address - Phone:731-641-8111
Practice Address - Fax:731-641-8110
Is Sole Proprietor?:No
Enumeration Date:2006-06-06
Last Update Date:2008-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNPT0038225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3729568Medicaid
TN33297OtherTLC FAMILY HEALTHPLAN
TNP00103288OtherPALMETTO GAB RR MEDICARE
TN4078075OtherBLUE CROSS BLUE SHIELD TN
TN12115OtherVA
TN33297OtherTLC FAMILY HEALTHPLAN
TN3729568Medicaid