Provider Demographics
NPI:1205500956
Name:COBB, SHANELE KANEISHA
Entity type:Individual
Prefix:
First Name:SHANELE
Middle Name:KANEISHA
Last Name:COBB
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 1:1475 1ST AVE SW
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:36265-3337
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1475 1ST AVE SW
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:AL
Practice Address - Zip Code:36265-3337
Practice Address - Country:US
Practice Address - Phone:256-435-9386
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-05
Last Update Date:2021-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALPTH10481225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist