=====================================================
General NPI Number Information
=====================================================
NPI Number | 1811329543
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SHANNON WILKINS DPT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/05/2013
-----------------------------------------------------
Last Update Date | 09/16/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 652 PINEY WOODS RD
-----------------------------------------------------
City | SCOOBA
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39358-7451
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 601-917-2568
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 652 PINEY WOODS RD
-----------------------------------------------------
City | SCOOBA
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39358-7451
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 601-917-2568
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
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 | 1225916
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------