Healthcare Provider Details

I. General information

NPI: 1235513334
Provider Name (Legal Business Name): SHANNON BURKE MS, LAT, ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/17/2015
Last Update Date: 09/10/2024
Certification Date: 09/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

650 HUEBNER RD
FORT RILEY KS
66442-4030
US

IV. Provider business mailing address

923 MEADOW LN
JUNCTION CITY KS
66441-3435
US

V. Phone/Fax

Practice location:
  • Phone: 847-924-8887
  • Fax:
Mailing address:
  • Phone: 847-924-8887
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number24-01517
License Number StateKS
# 2
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number096.003839
License Number StateIL

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: