Provider Demographics
NPI:1124243068
Name:SHANK, CHARLENE R
Entity type:Individual
Prefix:MS
First Name:CHARLENE
Middle Name:R
Last Name:SHANK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2505 BREMER RD
Mailing Address - Street 2:
Mailing Address - City:DOVER
Mailing Address - State:PA
Mailing Address - Zip Code:17315-2051
Mailing Address - Country:US
Mailing Address - Phone:717-292-5932
Mailing Address - Fax:717-266-0616
Practice Address - Street 1:300 HIGH ST
Practice Address - Street 2:
Practice Address - City:MANCHESTER
Practice Address - State:PA
Practice Address - Zip Code:17345-1508
Practice Address - Country:US
Practice Address - Phone:717-266-3644
Practice Address - Fax:717-266-0616
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PART001469A2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA2255A2300XOtherATHLETIC TRAINER