Provider Demographics
NPI:1841518214
Name:KLEINFELDER, SHANNON K (PT)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:K
Last Name:KLEINFELDER
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 VETERANS DR
Mailing Address - Street 2:
Mailing Address - City:MANTENO
Mailing Address - State:IL
Mailing Address - Zip Code:60950-9466
Mailing Address - Country:US
Mailing Address - Phone:815-468-6581
Mailing Address - Fax:
Practice Address - Street 1:1 VETERANS DR
Practice Address - Street 2:
Practice Address - City:MANTENO
Practice Address - State:IL
Practice Address - Zip Code:60950-9466
Practice Address - Country:US
Practice Address - Phone:815-468-6581
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-05-11
Last Update Date:2023-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL225100000X
IL070.0180242251G0304X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251G0304XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGeriatrics
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILP00865618OtherMEDICARE RR
IL214692026Medicare PIN
IL216859051Medicare PIN
ILP00865618OtherMEDICARE RR
IL209812007Medicare PIN