Healthcare Provider Details

I. General information

NPI: 1598075426
Provider Name (Legal Business Name): SHANNON MCIVOR
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/13/2010
Last Update Date: 06/30/2026
Certification Date: 06/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5532 JFK BLVD
NORTH LITTLE ROCK AR
72116-6708
US

IV. Provider business mailing address

5532 JFK BLVD APT 227
NORTH LITTLE ROCK AR
72116-6708
US

V. Phone/Fax

Practice location:
  • Phone: 501-588-3211
  • Fax:
Mailing address:
  • Phone: 501-588-3211
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT3261
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: