Provider Demographics
NPI:1982249090
Name:VINCENT, SHANNAN C (PT)
Entity Type:Individual
Prefix:
First Name:SHANNAN
Middle Name:C
Last Name:VINCENT
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 1:686 FOREST CT
Mailing Address - Street 2:
Mailing Address - City:NAPPANEE
Mailing Address - State:IN
Mailing Address - Zip Code:46550-2831
Mailing Address - Country:US
Mailing Address - Phone:574-773-0207
Mailing Address - Fax:
Practice Address - Street 1:3016 PORTAGE AVE
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46628-3501
Practice Address - Country:US
Practice Address - Phone:574-272-9011
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-12
Last Update Date:2019-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist