Provider Demographics
NPI:1902279136
Name:HERMAN, SHANNA MARIE (PHYSICAL THERAPIST)
Entity Type:Individual
Prefix:
First Name:SHANNA
Middle Name:MARIE
Last Name:HERMAN
Suffix:
Gender:F
Credentials:PHYSICAL THERAPIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:405 W MYRTLE ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83702-7658
Mailing Address - Country:US
Mailing Address - Phone:208-385-3420
Mailing Address - Fax:208-385-3421
Practice Address - Street 1:405 W MYRTLE ST
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83702-7658
Practice Address - Country:US
Practice Address - Phone:208-385-3420
Practice Address - Fax:208-385-3421
Is Sole Proprietor?:Yes
Enumeration Date:2015-11-10
Last Update Date:2015-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPT-4287225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist