Provider Demographics
NPI:1861567216
Name:LANDRY, SHANNON DAWN (PTA)
Entity type:Individual
Prefix:MRS
First Name:SHANNON
Middle Name:DAWN
Last Name:LANDRY
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7346 EAST INDIGO STREET
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85207
Mailing Address - Country:US
Mailing Address - Phone:480-854-7305
Mailing Address - Fax:
Practice Address - Street 1:6960 EAST BROADWAY ROAD
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85208
Practice Address - Country:US
Practice Address - Phone:480-807-9000
Practice Address - Fax:480-807-9234
Is Sole Proprietor?:No
Enumeration Date:2006-11-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ920036A225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist