Healthcare Provider Details

I. General information

NPI: 1922930122
Provider Name (Legal Business Name): SHANTA RENAE TIPTON MMT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/01/2026
Last Update Date: 06/01/2026
Certification Date: 06/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

114 E MAIN ST
RICHMOND KY
40475-1986
US

IV. Provider business mailing address

301 3RD ST
RAVENNA KY
40472-1410
US

V. Phone/Fax

Practice location:
  • Phone: 859-408-3776
  • Fax:
Mailing address:
  • Phone: 859-408-3776
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number302040
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: