Basic Information
| Provider Information | |||||||||
| NPI: | 1033743562 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CIPRIANO | ||||||||
| FirstName: | SHANNA | ||||||||
| MiddleName: | L | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PTA | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BUSSELL | ||||||||
| OtherFirstName: | SHANNA | ||||||||
| OtherMiddleName: | L | ||||||||
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| OtherCredential: | PTA | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 74 BRIGHTON RD | ||||||||
| Address2: | |||||||||
| City: | ATHENS | ||||||||
| State: | ME | ||||||||
| PostalCode: | 049124627 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2073994985 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 57 FAIRVIEW AVE | ||||||||
| Address2: | |||||||||
| City: | SKOWHEGAN | ||||||||
| State: | ME | ||||||||
| PostalCode: | 049761414 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2074747000 | ||||||||
| FaxNumber: | 2078584772 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/24/2020 | ||||||||
| LastUpdateDate: | 02/26/2020 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/26/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225200000X | PA3311 | ME | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapy Assistant |
No ID Information.