Provider Demographics
NPI:1780419309
Name:O'MALLEY, SHANNON
Entity type:Individual
Prefix:MS
First Name:SHANNON
Middle Name:
Last Name:O'MALLEY
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 1:2001 SPRING GARDEN ST APT 104
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19130-5011
Mailing Address - Country:US
Mailing Address - Phone:610-357-2289
Mailing Address - Fax:
Practice Address - Street 1:3500 CIVIC CENTER BLVD
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19104-4395
Practice Address - Country:US
Practice Address - Phone:610-357-2289
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-04
Last Update Date:2024-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Y00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersClinical Exercise Physiologist