Provider Demographics
NPI:1649360389
Name:WELLS, SHAWNA R (PT)
Entity type:Individual
Prefix:
First Name:SHAWNA
Middle Name:R
Last Name:WELLS
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:SHAWNA
Other - Middle Name:R
Other - Last Name:MARTIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:25 ARROYO RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:ALAMOGORDO
Mailing Address - State:NM
Mailing Address - Zip Code:88310-9726
Mailing Address - Country:US
Mailing Address - Phone:575-921-3074
Mailing Address - Fax:
Practice Address - Street 1:1090 MED PARK DR.
Practice Address - Street 2:
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88005-3236
Practice Address - Country:US
Practice Address - Phone:575-523-7243
Practice Address - Fax:575-525-5641
Is Sole Proprietor?:No
Enumeration Date:2006-10-13
Last Update Date:2022-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM1662225100000X
NMPT1662225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM000K8676Medicaid