Provider Demographics
NPI:1700819570
Name:SHAK, KELLY SUE (PT)
Entity Type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:SUE
Last Name:SHAK
Suffix:
Gender:F
Credentials:PT
Other - Prefix:MISS
Other - First Name:KELLY
Other - Middle Name:SUE
Other - Last Name:FINKEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:150 CHASE HOLLOW DR
Mailing Address - Street 2:
Mailing Address - City:NAZARETH
Mailing Address - State:PA
Mailing Address - Zip Code:18064-8104
Mailing Address - Country:US
Mailing Address - Phone:610-746-9432
Mailing Address - Fax:
Practice Address - Street 1:318 TOWN CENTER BLVD
Practice Address - Street 2:
Practice Address - City:EASTON
Practice Address - State:PA
Practice Address - Zip Code:18040-8366
Practice Address - Country:US
Practice Address - Phone:610-253-3300
Practice Address - Fax:610-253-1118
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPT013653L225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1700430OtherBLUE SHIELD
PAP00028342OtherRAILROAD MEDICARE
PA01133501OtherCAPITAL BLUE CROSS
PA1700430OtherBLUE SHIELD