Provider Demographics
NPI:1790963155
Name:SHIPLEY, MARY KRISTEN (PT)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:KRISTEN
Last Name:SHIPLEY
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:KRISTEN
Other - Middle Name:SHIPLEY
Other - Last Name:MINOR
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PT
Mailing Address - Street 1:2410 SUSANNAH ST
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37601-1748
Mailing Address - Country:US
Mailing Address - Phone:423-282-9011
Mailing Address - Fax:
Practice Address - Street 1:2410 SUSANNAH ST
Practice Address - Street 2:
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37601-1748
Practice Address - Country:US
Practice Address - Phone:423-282-9011
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-02-07
Last Update Date:2024-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC11480225100000X, 2251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCQ36607AOtherMEDICARE PTAN
NCQ36607BOtherMEDICARE
NC1790963155Medicaid