Provider Demographics
NPI:1215154141
Name:SHANAHAN POWELL, KOURTNE KAY (DC)
Entity type:Individual
Prefix:
First Name:KOURTNE
Middle Name:KAY
Last Name:SHANAHAN POWELL
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:KOURTNE
Other - Middle Name:KAY
Other - Last Name:SHANAHAN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DC
Mailing Address - Street 1:1310 TOWER LANE NE
Mailing Address - Street 2:
Mailing Address - City:CEDAR RAPIDS
Mailing Address - State:IA
Mailing Address - Zip Code:52402-7488
Mailing Address - Country:US
Mailing Address - Phone:319-366-2518
Mailing Address - Fax:319-366-5002
Practice Address - Street 1:1310 TOWER LANE NE
Practice Address - Street 2:
Practice Address - City:CEDAR RAPIDS
Practice Address - State:IA
Practice Address - Zip Code:52402-7488
Practice Address - Country:US
Practice Address - Phone:319-366-2518
Practice Address - Fax:319-366-5002
Is Sole Proprietor?:No
Enumeration Date:2007-04-20
Last Update Date:2016-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAA05972111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA58048OtherBLUE CROSS BLUE SHIELD