Healthcare Provider Details

I. General information

NPI: 1477461127
Provider Name (Legal Business Name): KIONNA MONAY SHAW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/01/2026
Last Update Date: 09/01/2026
Certification Date: 08/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2105 E. AGGIE ROAD
JONESBORO AR
72401
US

IV. Provider business mailing address

226 S JEFFERSON ST
RIPLEY TN
38063-1776
US

V. Phone/Fax

Practice location:
  • Phone: 870-972-3129
  • Fax:
Mailing address:
  • Phone: 901-697-9592
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: