Provider Demographics
NPI:1942701909
Name:PEMBLE, SHANNON KRISTINE
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:KRISTINE
Last Name:PEMBLE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14700 LAKE SHORE DRIVE
Mailing Address - Street 2:REHAB DEPT
Mailing Address - City:CHARLEVOIX
Mailing Address - State:MI
Mailing Address - Zip Code:49720
Mailing Address - Country:US
Mailing Address - Phone:231-547-8630
Mailing Address - Fax:231-547-8078
Practice Address - Street 1:14700 LAKE SHORE DRIVE
Practice Address - Street 2:REHAB DEPT
Practice Address - City:CHARLEVOIX
Practice Address - State:MI
Practice Address - Zip Code:49720
Practice Address - Country:US
Practice Address - Phone:231-547-8630
Practice Address - Fax:231-547-8078
Is Sole Proprietor?:No
Enumeration Date:2018-02-26
Last Update Date:2018-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501010622225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist