Provider Demographics
NPI:1801248398
Name:KIMBLEY, SHANNON (PTA)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:KIMBLEY
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 1:3362 S APPLEGATE DR
Mailing Address - Street 2:
Mailing Address - City:NEW PALESTINE
Mailing Address - State:IN
Mailing Address - Zip Code:46163-8937
Mailing Address - Country:US
Mailing Address - Phone:317-501-4059
Mailing Address - Fax:
Practice Address - Street 1:3362 S APPLEGATE DR
Practice Address - Street 2:
Practice Address - City:NEW PALESTINE
Practice Address - State:IN
Practice Address - Zip Code:46163-8937
Practice Address - Country:US
Practice Address - Phone:317-501-4059
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-07-07
Last Update Date:2016-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN06004189A225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant