Healthcare Provider Details

I. General information

NPI: 1265744684
Provider Name (Legal Business Name): SHANNON RENE PAITSELL JOHNSON P.T.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/14/2010
Last Update Date: 05/02/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2165 MEDICAL PARK DR
HICKORY NC
28602-8809
US

IV. Provider business mailing address

2165 MEDICAL PARK DR
HICKORY NC
28602-8809
US

V. Phone/Fax

Practice location:
  • Phone: 828-294-9130
  • Fax: 828-294-9159
Mailing address:
  • Phone: 828-294-9130
  • Fax: 828-294-9159

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number12698
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: