Provider Demographics
NPI:1124632401
Name:KELLETT, SHANNON NOEL (LAC)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:NOEL
Last Name:KELLETT
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6 S SYCAMORE ST
Mailing Address - Street 2:
Mailing Address - City:NEWTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:18940-1533
Mailing Address - Country:US
Mailing Address - Phone:267-968-1479
Mailing Address - Fax:
Practice Address - Street 1:6 S SYCAMORE ST
Practice Address - Street 2:
Practice Address - City:NEWTOWN
Practice Address - State:PA
Practice Address - Zip Code:18940-1533
Practice Address - Country:US
Practice Address - Phone:267-968-1479
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-03
Last Update Date:2020-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAAK001334171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist