Provider Demographics
NPI:1053727321
Name:KELLY, SHANNON MARIE (DPT)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:MARIE
Last Name:KELLY
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:675 E NICOLLET BLVD
Mailing Address - Street 2:OAK RIDGE EAST #135
Mailing Address - City:BURNSVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55337-6741
Mailing Address - Country:US
Mailing Address - Phone:952-892-2605
Mailing Address - Fax:
Practice Address - Street 1:675 E NICOLLET BLVD
Practice Address - Street 2:OAK RIDGE EAST #135
Practice Address - City:BURNSVILLE
Practice Address - State:MN
Practice Address - Zip Code:55337-6741
Practice Address - Country:US
Practice Address - Phone:952-892-2605
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-07-08
Last Update Date:2014-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN3143225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist