Healthcare Provider Details

I. General information

NPI: 1760399232
Provider Name (Legal Business Name): SHANNON PAULINE PULKOWSKI PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/27/2026
Last Update Date: 08/27/2026
Certification Date: 08/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1953 MAUMEE DR
VALPARAISO IN
46385-6159
US

IV. Provider business mailing address

1953 MAUMEE DR
VALPARAISO IN
46385-6159
US

V. Phone/Fax

Practice location:
  • Phone: 219-921-6363
  • Fax:
Mailing address:
  • Phone: 219-921-6363
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number06005152A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: