Provider Demographics
NPI:1104276120
Name:KETCHAMCONNELLY, SHASTA (DPT)
Entity type:Individual
Prefix:
First Name:SHASTA
Middle Name:
Last Name:KETCHAMCONNELLY
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:508 S 1ST AVE
Mailing Address - Street 2:
Mailing Address - City:DANVILLE
Mailing Address - State:IA
Mailing Address - Zip Code:52623-9609
Mailing Address - Country:US
Mailing Address - Phone:319-750-2799
Mailing Address - Fax:
Practice Address - Street 1:508 S 1ST AVE
Practice Address - Street 2:
Practice Address - City:DANVILLE
Practice Address - State:IA
Practice Address - Zip Code:52623-9609
Practice Address - Country:US
Practice Address - Phone:319-750-2799
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-21
Last Update Date:2016-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1221789225100000X
HI3843225100000X
DC871828225100000X
IA080290225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist