Provider Demographics
NPI:1740316132
Name:NEALON, SHANNON ROSE (PT)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:ROSE
Last Name:NEALON
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2403 S 133RD PLZ
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68144-5905
Mailing Address - Country:US
Mailing Address - Phone:402-330-8433
Mailing Address - Fax:402-330-8616
Practice Address - Street 1:2953 S 168TH ST
Practice Address - Street 2:SUITE 100
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68130-2000
Practice Address - Country:US
Practice Address - Phone:402-593-7345
Practice Address - Fax:402-593-0882
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-27
Last Update Date:2008-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE2534225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NEP00453826OtherMEDIARE RR
NEP00453826OtherMEDIARE RR