=====================================================
General NPI Number Information
=====================================================
NPI Number | 1699802553
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SHAWNA ELISA BENNER-ERICKSON MPT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/27/2007
-----------------------------------------------------
Last Update Date | 07/09/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1005 HIGHWAY 2
-----------------------------------------------------
City | SANDPOINT
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83864-1702
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-263-1632
-----------------------------------------------------
Fax | 208-255-2066
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1005 HIGHWAY 2
-----------------------------------------------------
City | SANDPOINT
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83864-1702
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-263-1632
-----------------------------------------------------
Fax | 208-255-2066
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | PT 1783
-----------------------------------------------------
License Number State | ID
-----------------------------------------------------