Provider Demographics
NPI:1922769272
Name:MACKLEM, SHANNON DONNEL (PTA)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:DONNEL
Last Name:MACKLEM
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:191 SWANSON AVE STE 102
Mailing Address - Street 2:
Mailing Address - City:LAKE HAVASU CITY
Mailing Address - State:AZ
Mailing Address - Zip Code:86403-6699
Mailing Address - Country:US
Mailing Address - Phone:928-855-7880
Mailing Address - Fax:
Practice Address - Street 1:191 SWANSON AVE STE 102
Practice Address - Street 2:
Practice Address - City:LAKE HAVASU CITY
Practice Address - State:AZ
Practice Address - Zip Code:86403-6699
Practice Address - Country:US
Practice Address - Phone:928-855-7880
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-07
Last Update Date:2022-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ011003225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant