Provider Demographics
NPI:1811517360
Name:HERNDON, SHAWNA RENAE GALONDA (LMT)
Entity type:Individual
Prefix:
First Name:SHAWNA
Middle Name:RENAE GALONDA
Last Name:HERNDON
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16 E REYNOLDS ST
Mailing Address - Street 2:
Mailing Address - City:CASEYVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62232-1014
Mailing Address - Country:US
Mailing Address - Phone:618-223-8333
Mailing Address - Fax:618-551-4709
Practice Address - Street 1:16 E REYNOLDS ST
Practice Address - Street 2:
Practice Address - City:CASEYVILLE
Practice Address - State:IL
Practice Address - Zip Code:62232-1014
Practice Address - Country:US
Practice Address - Phone:618-223-8333
Practice Address - Fax:618-551-4709
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-24
Last Update Date:2020-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL227013189225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist