Provider Demographics
NPI:1780959528
Name:BAKER, SHANA NICOLE (PTA)
Entity type:Individual
Prefix:MRS
First Name:SHANA
Middle Name:NICOLE
Last Name:BAKER
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 1:310 OLD SHARPSVILLE LN
Mailing Address - Street 2:
Mailing Address - City:HARRODSBURG
Mailing Address - State:KY
Mailing Address - Zip Code:40330-8018
Mailing Address - Country:US
Mailing Address - Phone:859-481-3299
Mailing Address - Fax:
Practice Address - Street 1:420 E GRUNDY AVE
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:KY
Practice Address - Zip Code:40069-1173
Practice Address - Country:US
Practice Address - Phone:859-336-7771
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-03-13
Last Update Date:2012-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYA02506225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant