Healthcare Provider Details

I. General information

NPI: 1982142469
Provider Name (Legal Business Name): SHANNON GRAY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/06/2017
Last Update Date: 02/06/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2200 CONNER RD
HEBRON KY
41048-8142
US

IV. Provider business mailing address

7642 PLOW SHARE CT
FLORENCE KY
41042-8066
US

V. Phone/Fax

Practice location:
  • Phone: 859-814-0022
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberA01652
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: