Healthcare Provider Details

I. General information

NPI: 1932090537
Provider Name (Legal Business Name): SHANNON ELIZABETH KELLY PT, DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/11/2025
Last Update Date: 07/11/2025
Certification Date: 07/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2736 MEDINA RD STE 108
MEDINA OH
44256-9801
US

IV. Provider business mailing address

134 3RD ST NW
NEW PHILADELPHIA OH
44663-3761
US

V. Phone/Fax

Practice location:
  • Phone: 330-867-2240
  • Fax:
Mailing address:
  • Phone: 330-987-3884
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT021871
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: