Provider Demographics
NPI:1255804589
Name:DOUGLAS, SHAUNA LYNN (PTA)
Entity type:Individual
Prefix:
First Name:SHAUNA
Middle Name:LYNN
Last Name:DOUGLAS
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 1:155 RACCOON VALLEY RD
Mailing Address - Street 2:
Mailing Address - City:MAYNARDVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37807-3144
Mailing Address - Country:US
Mailing Address - Phone:865-200-6372
Mailing Address - Fax:
Practice Address - Street 1:5321 BEVERLY PARK CIR
Practice Address - Street 2:
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37918-9253
Practice Address - Country:US
Practice Address - Phone:865-687-1321
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-09
Last Update Date:2019-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN0000005604225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant