Provider Demographics
NPI:1669101770
Name:HESTOR, SHANNON DAWN (ATC, LAT)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:DAWN
Last Name:HESTOR
Suffix:
Gender:F
Credentials:ATC, LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 GROVE LN APT 813
Mailing Address - Street 2:
Mailing Address - City:INDIANA
Mailing Address - State:PA
Mailing Address - Zip Code:15701-2128
Mailing Address - Country:US
Mailing Address - Phone:717-991-3283
Mailing Address - Fax:
Practice Address - Street 1:660 S 11TH ST
Practice Address - Street 2:
Practice Address - City:INDIANA
Practice Address - State:PA
Practice Address - Zip Code:17705
Practice Address - Country:US
Practice Address - Phone:717-991-3283
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-06
Last Update Date:2022-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PART0078522081S0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2081S0010XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationSports Medicine