Provider Demographics
NPI:1154964757
Name:PERRY, SHADONNA ROSHAWN
Entity type:Individual
Prefix:
First Name:SHADONNA
Middle Name:ROSHAWN
Last Name:PERRY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:SHADONNA
Other - Middle Name:ROSHAWN
Other - Last Name:BANKS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3923 AUTUMN RIDGE CT APT 101
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38115-0914
Mailing Address - Country:US
Mailing Address - Phone:470-991-4088
Mailing Address - Fax:
Practice Address - Street 1:119 RACINE ST STE 103
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38111-2729
Practice Address - Country:US
Practice Address - Phone:470-991-4088
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-26
Last Update Date:2019-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier