1124243068 NPI number — MS. CHARLENE R. SHANK

Table of content: MS. CHARLENE R. SHANK (NPI 1124243068)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1124243068 NPI number — MS. CHARLENE R. SHANK

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SHANK
Provider First Name:
CHARLENE
Provider Middle Name:
R.
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1124243068
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2505 BREMER RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DOVER
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
17315-2051
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
717-292-5932
Provider Business Mailing Address Fax Number:
717-266-0616

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
300 HIGH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MANCHESTER
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
17345-1508
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
717-266-3644
Provider Business Practice Location Address Fax Number:
717-266-0616
Provider Enumeration Date:
04/16/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 2255A2300X , with the licence number:  RT001469A , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 2255A2300X . This is a "ATHLETIC TRAINER" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".