Provider Demographics
NPI:1649286576
Name:SHAMBLIN, KATHY LYNN (OD)
Entity type:Individual
Prefix:DR
First Name:KATHY
Middle Name:LYNN
Last Name:SHAMBLIN
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:915 COLLOREDO BLVD
Mailing Address - Street 2:
Mailing Address - City:SHELBYVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37160-2780
Mailing Address - Country:US
Mailing Address - Phone:931-684-2197
Mailing Address - Fax:931-684-8562
Practice Address - Street 1:915 COLLOREDO BLVD
Practice Address - Street 2:
Practice Address - City:SHELBYVILLE
Practice Address - State:TN
Practice Address - Zip Code:37160-2780
Practice Address - Country:US
Practice Address - Phone:931-684-2197
Practice Address - Fax:931-684-8562
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-31
Last Update Date:2012-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNTN1074152WV0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152WV0400XEye and Vision Services ProvidersOptometristVision Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3596029Medicaid
TN3596029Medicaid
TN0826140001Medicare NSC