Provider Demographics
NPI:1982900114
Name:KELLY, SHAUNA (PT)
Entity Type:Individual
Prefix:MISS
First Name:SHAUNA
Middle Name:
Last Name:KELLY
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 1:64 DANBURY RD
Mailing Address - Street 2:
Mailing Address - City:WILTON
Mailing Address - State:CT
Mailing Address - Zip Code:06897-4429
Mailing Address - Country:US
Mailing Address - Phone:800-278-0332
Mailing Address - Fax:800-970-5001
Practice Address - Street 1:1600 JOSEPH DR
Practice Address - Street 2:
Practice Address - City:BRYAN
Practice Address - State:TX
Practice Address - Zip Code:77802-1502
Practice Address - Country:US
Practice Address - Phone:979-776-2411
Practice Address - Fax:979-776-4986
Is Sole Proprietor?:Yes
Enumeration Date:2011-02-05
Last Update Date:2011-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1195167171000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171000000XOther Service ProvidersMilitary Health Care Provider