Provider Demographics
NPI:1831771807
Name:BUBNACK, SHANNON (DPT)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:BUBNACK
Suffix:
Gender:
Credentials:DPT
Other - Prefix:
Other - First Name:SHANNON
Other - Middle Name:M
Other - Last Name:RAYHONS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2122 YORK RD STE 300
Mailing Address - Street 2:
Mailing Address - City:OAK BROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60523-1925
Mailing Address - Country:US
Mailing Address - Phone:630-575-1980
Mailing Address - Fax:630-928-5080
Practice Address - Street 1:1604 NW STATE ST STE 102
Practice Address - Street 2:
Practice Address - City:ANKENY
Practice Address - State:IA
Practice Address - Zip Code:50023-1484
Practice Address - Country:US
Practice Address - Phone:515-965-4594
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-28
Last Update Date:2025-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070-025827225100000X
IA131859225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist