Provider Demographics
NPI:1184070997
Name:QUINTERO, SHANNON (PTA)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:QUINTERO
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 1:1061 NW 46TH PL
Mailing Address - Street 2:
Mailing Address - City:OCALA
Mailing Address - State:FL
Mailing Address - Zip Code:34475-9574
Mailing Address - Country:US
Mailing Address - Phone:321-696-5158
Mailing Address - Fax:
Practice Address - Street 1:101 LIBERTY LN
Practice Address - Street 2:
Practice Address - City:ANSON
Practice Address - State:TX
Practice Address - Zip Code:79501-2197
Practice Address - Country:US
Practice Address - Phone:325-823-2141
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-11
Last Update Date:2022-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2167050225200000X
FL26913225200000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant