Healthcare Provider Details

I. General information

NPI: 1689340291
Provider Name (Legal Business Name): SHANNON WYNN DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/23/2021
Last Update Date: 07/28/2026
Certification Date: 07/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

580 N 54TH ST STE 1&2
CHANDLER AZ
85226-2555
US

IV. Provider business mailing address

9010 S PRIEST DR APT 3170
TEMPE AZ
85284-1128
US

V. Phone/Fax

Practice location:
  • Phone: 702-556-1163
  • Fax:
Mailing address:
  • Phone: 702-556-1163
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberLPT-034826
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License NumberLPT-034826
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: