MEDICARE: MS. ANITA ELLEN SHIPLEY

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225200000X	Physical Therapy Assistant	2086360	TX
2	225200000X	Physical Therapy Assistant	TEI003078	PA
3	225200000X	Physical Therapy Assistant	06004034A	IN

General Provider Information

NPI Number	:	1689948556
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. ANITA ELLEN SHIPLEY

Provider Business Mailing Address
First Line	:	66325 REDWOOD RD
Second Line	:
City	:	NORTH LIBERTY
State	:	IN
Zip	:	46554-9456
Country	:	US
Telephone Number	:	574-274-7881
Fax Number	:

Provider Business Practice Location Address
First Line	:	66325 REDWOOD RD
Second Line	:
City	:	NORTH LIBERTY
State	:	IN
Zip	:	46554-9456
Country	:	US
Telephone Number	:	574-274-7881
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/23/2012
Last Update Date	:	02/23/2012

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