Provider Demographics
NPI:1427273127
Name:BUSSELL, SHELLY ANN (PTA)
Entity type:Individual
Prefix:
First Name:SHELLY
Middle Name:ANN
Last Name:BUSSELL
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:SHELLY
Other - Middle Name:ANN
Other - Last Name:RIKANSRUD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PTA
Mailing Address - Street 1:1399 MORIAH LN
Mailing Address - Street 2:
Mailing Address - City:SOUTHSIDE
Mailing Address - State:AL
Mailing Address - Zip Code:35907-0750
Mailing Address - Country:US
Mailing Address - Phone:865-368-0894
Mailing Address - Fax:
Practice Address - Street 1:1399 MORIAH LN
Practice Address - Street 2:
Practice Address - City:SOUTHSIDE
Practice Address - State:AL
Practice Address - Zip Code:35907-0750
Practice Address - Country:US
Practice Address - Phone:865-368-0894
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNPTA3453225200000X
TX2060707225200000X
WYPTA555225200000X
FLPTA1511225200000X
GAPTA2216225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant