Provider Demographics
NPI:1356423628
Name:RICHARD, SHANNON ANN (DPT)
Entity type:Individual
Prefix:MRS
First Name:SHANNON
Middle Name:ANN
Last Name:RICHARD
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3417 ANDOVER HILLS PL
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23294-5343
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:10124 W BROAD ST STE K
Practice Address - Street 2:
Practice Address - City:GLEN ALLEN
Practice Address - State:VA
Practice Address - Zip Code:23060-3330
Practice Address - Country:US
Practice Address - Phone:804-273-6656
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-19
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305203839225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist