Provider Demographics
NPI:1720499155
Name:CHURCH, SHALLON ANDREA (LMT, RCR)
Entity Type:Individual
Prefix:
First Name:SHALLON
Middle Name:ANDREA
Last Name:CHURCH
Suffix:
Gender:F
Credentials:LMT, RCR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1171 EAST HIGHWAY 11-E
Mailing Address - Street 2:SUITE 103
Mailing Address - City:TALBOTT
Mailing Address - State:TN
Mailing Address - Zip Code:37877
Mailing Address - Country:US
Mailing Address - Phone:423-737-8020
Mailing Address - Fax:
Practice Address - Street 1:1171 EAST HIGHWAY 11-E
Practice Address - Street 2:SUITE 102
Practice Address - City:TALBOTT
Practice Address - State:TN
Practice Address - Zip Code:37877
Practice Address - Country:US
Practice Address - Phone:423-737-8020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-05-20
Last Update Date:2014-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN3283225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist