Provider Demographics
NPI:1780416768
Name:SHANAFELT, KAITLIN
Entity type:Individual
Prefix:
First Name:KAITLIN
Middle Name:
Last Name:SHANAFELT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:171 FREDERICK ST
Mailing Address - Street 2:
Mailing Address - City:TYRONE
Mailing Address - State:PA
Mailing Address - Zip Code:16686-6801
Mailing Address - Country:US
Mailing Address - Phone:814-650-4004
Mailing Address - Fax:
Practice Address - Street 1:171 FREDERICK ST
Practice Address - Street 2:
Practice Address - City:TYRONE
Practice Address - State:PA
Practice Address - Zip Code:16686-6801
Practice Address - Country:US
Practice Address - Phone:814-650-4004
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-17
Last Update Date:2024-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PATEI006569225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant