Provider Demographics
NPI:1528588605
Name:GREEN, SHANNON J (DC)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:J
Last Name:GREEN
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:636 W BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:NORTH LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72114-5526
Mailing Address - Country:US
Mailing Address - Phone:501-374-1153
Mailing Address - Fax:501-374-6213
Practice Address - Street 1:636 W BROADWAY ST
Practice Address - Street 2:
Practice Address - City:NORTH LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72114-5526
Practice Address - Country:US
Practice Address - Phone:501-374-1153
Practice Address - Fax:501-374-6213
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-21
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPENDING111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor