Basic Information
Provider Information | |||||||||
NPI: | 1255364493 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | WEICHERS | ||||||||
FirstName: | SHANTELLE | ||||||||
MiddleName: | A | ||||||||
NamePrefix: | MS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | ATC, CSCS | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 5426 CAREY DR | ||||||||
Address2: |   | ||||||||
City: | CEDAR FALLS | ||||||||
State: | IA | ||||||||
PostalCode: | 506137039 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3192392738 | ||||||||
FaxNumber: | 3192680321 | ||||||||
Practice Location | |||||||||
Address1: | 1731 W RIDGEWAY AVE | ||||||||
Address2: | STE 600 | ||||||||
City: | WATERLOO | ||||||||
State: | IA | ||||||||
PostalCode: | 507014595 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3198335900 | ||||||||
FaxNumber: | 3198335901 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/09/2006 | ||||||||
LastUpdateDate: | 07/08/2007 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2255A2300X | 00201 | IA | Y |   | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Specialist/Technologist | Athletic Trainer |
No ID Information.