Healthcare Provider Details

I. General information

NPI: 1720499155
Provider Name (Legal Business Name): SHALLON ANDREA CHURCH L.M.T., R.C.R
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/20/2014
Last Update Date: 05/20/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1171 EAST HIGHWAY 11-E SUITE 102
TALBOTT TN
37877
US

IV. Provider business mailing address

1171 EAST HIGHWAY 11-E SUITE 103
TALBOTT TN
37877
US

V. Phone/Fax

Practice location:
  • Phone: 423-737-8020
  • Fax:
Mailing address:
  • Phone: 423-737-8020
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number3283
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: