Provider Demographics
NPI:1982963823
Name:BANNISTER, SHAKIRA L (PT)
Entity type:Individual
Prefix:MRS
First Name:SHAKIRA
Middle Name:L
Last Name:BANNISTER
Suffix:
Gender:F
Credentials:PT
Other - Prefix:MS
Other - First Name:SHAKIRA
Other - Middle Name:L
Other - Last Name:MASON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:3975 BETHANIA LOT DR APT 303
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27106-1772
Mailing Address - Country:US
Mailing Address - Phone:336-923-5432
Mailing Address - Fax:
Practice Address - Street 1:16405 NORTHCROSS DR
Practice Address - Street 2:
Practice Address - City:HUNTERSVILLE
Practice Address - State:NC
Practice Address - Zip Code:28078-5091
Practice Address - Country:US
Practice Address - Phone:800-557-9535
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-05-13
Last Update Date:2012-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC125692251G0304X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251G0304XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGeriatrics