Provider Demographics
NPI:1700258761
Name:SHANER, KELLY (ATC)
Entity Type:Individual
Prefix:MS
First Name:KELLY
Middle Name:
Last Name:SHANER
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23789 490TH AVE
Mailing Address - Street 2:
Mailing Address - City:SANBORN
Mailing Address - State:MN
Mailing Address - Zip Code:56083-4106
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:100 FALLWOOD RD
Practice Address - Street 2:
Practice Address - City:REDWOOD FALLS
Practice Address - State:MN
Practice Address - Zip Code:56283-1828
Practice Address - Country:US
Practice Address - Phone:507-637-4500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-10-29
Last Update Date:2015-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN26872255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer