Healthcare Provider Details

I. General information

NPI: 1841122827
Provider Name (Legal Business Name): SHANESE KYM PURCELL
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/02/2026
Last Update Date: 06/02/2026
Certification Date: 06/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5210 E HAMPTON AVE APT 2159
MESA AZ
85206-3465
US

IV. Provider business mailing address

5210 E HAMPTON AVE APT 2159
MESA AZ
85206-3465
US

V. Phone/Fax

Practice location:
  • Phone: 860-608-1583
  • Fax:
Mailing address:
  • Phone: 860-608-1583
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMT-27632
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: