Provider Demographics
NPI:1124420807
Name:KRISKO, SHANNON MICHELLE
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:MICHELLE
Last Name:KRISKO
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 1:6 MORRILL PL
Mailing Address - Street 2:
Mailing Address - City:AMESBURY
Mailing Address - State:MA
Mailing Address - Zip Code:01913-3502
Mailing Address - Country:US
Mailing Address - Phone:978-388-3500
Mailing Address - Fax:
Practice Address - Street 1:6 MORRILL PL
Practice Address - Street 2:
Practice Address - City:AMESBURY
Practice Address - State:MA
Practice Address - Zip Code:01913-3502
Practice Address - Country:US
Practice Address - Phone:978-388-3500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-24
Last Update Date:2014-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA3808224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant