Provider Demographics
NPI:1942188958
Name:SHANAHAN, KRISTI AMBER (DPT)
Entity type:Individual
Prefix:
First Name:KRISTI
Middle Name:AMBER
Last Name:SHANAHAN
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 1:1263 BENNETT AVE STE 2
Mailing Address - Street 2:
Mailing Address - City:BURLEY
Mailing Address - State:ID
Mailing Address - Zip Code:83318-4906
Mailing Address - Country:US
Mailing Address - Phone:086-781-1911
Mailing Address - Fax:208-678-1214
Practice Address - Street 1:1263 BENNETT AVE STE 2
Practice Address - Street 2:
Practice Address - City:BURLEY
Practice Address - State:ID
Practice Address - Zip Code:83318-4906
Practice Address - Country:US
Practice Address - Phone:086-781-1911
Practice Address - Fax:208-678-1214
Is Sole Proprietor?:No
Enumeration Date:2025-08-26
Last Update Date:2025-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID3171576225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist