Provider Demographics
NPI:1982278974
Name:VAUGHAN, SHANNON (LPTA)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:VAUGHAN
Suffix:
Gender:F
Credentials:LPTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2600 W HUDSON RD
Mailing Address - Street 2:
Mailing Address - City:ROGERS
Mailing Address - State:AR
Mailing Address - Zip Code:72756-2028
Mailing Address - Country:US
Mailing Address - Phone:479-936-1061
Mailing Address - Fax:
Practice Address - Street 1:2600 W HUDSON RD
Practice Address - Street 2:
Practice Address - City:ROGERS
Practice Address - State:AR
Practice Address - Zip Code:72756-2028
Practice Address - Country:US
Practice Address - Phone:479-621-6126
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-14
Last Update Date:2021-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR225200000X225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant