Healthcare Provider Details

I. General information

NPI: 1689597098
Provider Name (Legal Business Name): SHANNON WILKS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/03/2026
Last Update Date: 08/03/2026
Certification Date: 07/31/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2355 N CENTER ST STE 105
FAYETTEVILLE AR
72701-8210
US

IV. Provider business mailing address

2355 N CENTER ST STE 105
FAYETTEVILLE AR
72701-8210
US

V. Phone/Fax

Practice location:
  • Phone: 870-916-5455
  • Fax: 870-277-0896
Mailing address:
  • Phone: 870-916-5455
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberPTA2674
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: