1861812711 NPI number — SHANNEN BROWN MS, ATC, LAT

Table of content: YANCY SUJELY ALFARO (NPI 1972083483)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1861812711 NPI number — SHANNEN BROWN MS, ATC, LAT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BROWN
Provider First Name:
SHANNEN
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MS, ATC, LAT
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:
1861812711
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/26/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4371 NEW SHEPHERDSVILLE RD
Provider Second Line Business Mailing Address:
SCN OFFICE BUILDING B, SUITE 110
Provider Business Mailing Address City Name:
BARDSTOWN
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
40004-8040
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
502-350-5367
Provider Business Mailing Address Fax Number:
502-350-5376

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4371 NEW SHEPHERDSVILLE RD
Provider Second Line Business Practice Location Address:
SCN OFFICE BUILDING B, SUITE 110
Provider Business Practice Location Address City Name:
BARDSTOWN
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
40004-8040
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
502-350-5367
Provider Business Practice Location Address Fax Number:
502-350-5376
Provider Enumeration Date:
04/18/2014

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:  AT1105 , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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