Provider Demographics
NPI:1316273444
Name:SPEAGLE, SHANNON (DPT)
Entity type:Individual
Prefix:DR
First Name:SHANNON
Middle Name:
Last Name:SPEAGLE
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 1:7654 N 19TH AVE
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85021-7025
Mailing Address - Country:US
Mailing Address - Phone:602-336-6883
Mailing Address - Fax:
Practice Address - Street 1:7654 N 19TH AVE
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85021-7025
Practice Address - Country:US
Practice Address - Phone:602-336-6883
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-10-23
Last Update Date:2011-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ8254225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist