Provider Demographics
NPI:1720089311
Name:CLARK, SHANNON LYNN (DC)
Entity Type:Individual
Prefix:DR
First Name:SHANNON
Middle Name:LYNN
Last Name:CLARK
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:423 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:REINBECK
Mailing Address - State:IA
Mailing Address - Zip Code:50669-1049
Mailing Address - Country:US
Mailing Address - Phone:319-345-2831
Mailing Address - Fax:319-345-6626
Practice Address - Street 1:423 MAIN ST
Practice Address - Street 2:
Practice Address - City:REINBECK
Practice Address - State:IA
Practice Address - Zip Code:50669-1049
Practice Address - Country:US
Practice Address - Phone:319-345-2831
Practice Address - Fax:319-345-6626
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-03
Last Update Date:2012-09-20
Deactivation Date:2006-03-22
Deactivation Code:
Reactivation Date:2006-03-27
Provider Licenses
StateLicense IDTaxonomies
IAA05831111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0118703Medicaid
IA0118703Medicaid
IA21064Medicare ID - Type Unspecified