Provider Demographics
NPI:1922264860
Name:SHANNON, KELLY LYNN (DPT)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:LYNN
Last Name:SHANNON
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:LYNN
Other - Last Name:DAVIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPT
Mailing Address - Street 1:933 COCHRAN ST
Mailing Address - Street 2:
Mailing Address - City:DANIEL ISLAND
Mailing Address - State:SC
Mailing Address - Zip Code:29492-7577
Mailing Address - Country:US
Mailing Address - Phone:240-447-5226
Mailing Address - Fax:
Practice Address - Street 1:933 COCHRAN ST
Practice Address - Street 2:
Practice Address - City:DANIEL ISLAND
Practice Address - State:SC
Practice Address - Zip Code:29492-7577
Practice Address - Country:US
Practice Address - Phone:240-447-5226
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-30
Last Update Date:2021-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC105572251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic