Provider Demographics
NPI:1740457910
Name:CAMPBELL, SHANNON RENE (PTA)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:RENE
Last Name:CAMPBELL
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1182
Mailing Address - Street 2:
Mailing Address - City:ANDERSON
Mailing Address - State:IN
Mailing Address - Zip Code:46015-1182
Mailing Address - Country:US
Mailing Address - Phone:765-649-1900
Mailing Address - Fax:765-649-4992
Practice Address - Street 1:1215 JACKSON ST
Practice Address - Street 2:
Practice Address - City:ANDERSON
Practice Address - State:IN
Practice Address - Zip Code:46016-1652
Practice Address - Country:US
Practice Address - Phone:765-649-1900
Practice Address - Fax:765-649-4992
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-15
Last Update Date:2008-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN06003472A225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant