Provider Demographics
NPI:1336528736
Name:KANE, SHANNON (MAT)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:KANE
Suffix:
Gender:F
Credentials:MAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:374 S GRAND BLVD
Mailing Address - Street 2:BOX 58
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63103-2415
Mailing Address - Country:US
Mailing Address - Phone:850-454-6487
Mailing Address - Fax:
Practice Address - Street 1:374 S GRAND BLVD
Practice Address - Street 2:BOX 58
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63103-2415
Practice Address - Country:US
Practice Address - Phone:850-454-6487
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-05-19
Last Update Date:2015-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer