Provider Demographics
NPI:1528609781
Name:SHANNON, AUDREY C (DPT)
Entity type:Individual
Prefix:DR
First Name:AUDREY
Middle Name:C
Last Name:SHANNON
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 1:51 LANARK RD
Mailing Address - Street 2:
Mailing Address - City:STAMFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06902-7819
Mailing Address - Country:US
Mailing Address - Phone:203-981-4001
Mailing Address - Fax:
Practice Address - Street 1:2021 K ST NW STE 202
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20006-1003
Practice Address - Country:US
Practice Address - Phone:202-466-9717
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-30
Last Update Date:2023-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT12428225100000X
DCPT872546225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist