Provider Demographics
NPI:1063720639
Name:POWELL, LADONNA SHANE (PTA)
Entity type:Individual
Prefix:MRS
First Name:LADONNA
Middle Name:SHANE
Last Name:POWELL
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 1:1900 PETSCH LN
Mailing Address - Street 2:
Mailing Address - City:HOPKINSVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:42240-8608
Mailing Address - Country:US
Mailing Address - Phone:270-887-3500
Mailing Address - Fax:
Practice Address - Street 1:1900 PETSCH LN
Practice Address - Street 2:
Practice Address - City:HOPKINSVILLE
Practice Address - State:KY
Practice Address - Zip Code:42240-8608
Practice Address - Country:US
Practice Address - Phone:270-887-3500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-16
Last Update Date:2010-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYA01953225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant