Provider Demographics
NPI:1942460241
Name:SHORES, KRISTEN BROOKE (MS,CCC-SLP)
Entity Type:Individual
Prefix:MS
First Name:KRISTEN
Middle Name:BROOKE
Last Name:SHORES
Suffix:
Gender:F
Credentials:MS,CCC-SLP
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 298
Mailing Address - Street 2:
Mailing Address - City:SPARTA
Mailing Address - State:TN
Mailing Address - Zip Code:38583-0298
Mailing Address - Country:US
Mailing Address - Phone:931-836-2211
Mailing Address - Fax:931-836-2230
Practice Address - Street 1:34 GRACEY ST
Practice Address - Street 2:
Practice Address - City:SPARTA
Practice Address - State:TN
Practice Address - Zip Code:38583-2046
Practice Address - Country:US
Practice Address - Phone:931-836-2211
Practice Address - Fax:931-836-2230
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-11
Last Update Date:2008-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNSP 0000003641314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility