Provider Demographics
NPI:1649055476
Name:WALLIN, SHANNON RENE (ATC)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:RENE
Last Name:WALLIN
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:SHANNON
Other - Middle Name:RENE
Other - Last Name:HARMS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:ATC
Mailing Address - Street 1:2000 MOWRY AVE
Mailing Address - Street 2:
Mailing Address - City:FREMONT
Mailing Address - State:CA
Mailing Address - Zip Code:94538-1746
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:41717 PALM AVE
Practice Address - Street 2:
Practice Address - City:FREMONT
Practice Address - State:CA
Practice Address - Zip Code:94539-4722
Practice Address - Country:US
Practice Address - Phone:510-657-3600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-29
Last Update Date:2023-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer