Provider Demographics
NPI:1679787964
Name:SMITH, SHANNON J (PT)
Entity type:Individual
Prefix:MRS
First Name:SHANNON
Middle Name:J
Last Name:SMITH
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:502 6TH ST
Mailing Address - Street 2:
Mailing Address - City:NEWPORT
Mailing Address - State:TN
Mailing Address - Zip Code:37821-3725
Mailing Address - Country:US
Mailing Address - Phone:423-237-8889
Mailing Address - Fax:
Practice Address - Street 1:502 6TH ST
Practice Address - Street 2:
Practice Address - City:NEWPORT
Practice Address - State:TN
Practice Address - Zip Code:37821-3725
Practice Address - Country:US
Practice Address - Phone:423-237-8889
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-09
Last Update Date:2020-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNPT0000005471225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3650038Medicaid
TN4156222OtherBLUE CROSS BLUE SHIELD
TN3650038Medicaid