Healthcare Provider Details

I. General information

NPI: 1639073430
Provider Name (Legal Business Name): SHANNON NIXON
Entity Type: Individual
Gender:
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/05/2026
Last Update Date: 10/05/2026
Certification Date: 10/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9 LINCOLN HWY STE E
EDISON NJ
08820-3966
US

IV. Provider business mailing address

23 POE AVE
WYNCOTE PA
19095-2903
US

V. Phone/Fax

Practice location:
  • Phone: 732-321-1855
  • Fax:
Mailing address:
  • Phone: 856-426-9247
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: