Shasta Ketchamconnelly, DPT

Primary specialty

Physical TherapistTaxonomy code 225100000X

License

1221789 Issued in TX

Practice address

508 S 1St Ave
Danville, IA 52623-9609

Phone

(319) 750-2799

NPI assigned

Jun 21, 2016

Last updated

Jun 21, 2016By the provider in NPPES

Sex

Female

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 4

Addresses

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Medicare enrollment (NPD)

Not enrolled

State licenses

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1466467200000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1466467200000",
    "number": "1104276120",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "508 S 1ST AVE",
            "city": "DANVILLE",
            "state": "IA",
            "postal_code": "526239609",
            "telephone_number": "319-750-2799"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "508 S 1ST AVE",
            "city": "DANVILLE",
            "state": "IA",
            "postal_code": "526239609",
            "telephone_number": "319-750-2799"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "KETCHAMCONNELLY",
        "first_name": "SHASTA",
        "credential": "DPT",
        "sole_proprietor": "NO",
        "sex": "F",
        "enumeration_date": "2016-06-21",
        "last_updated": "2016-06-21",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "225100000X",
            "taxonomy_group": "",
            "desc": "Physical Therapist",
            "state": "TX",
            "license": "1221789",
            "primary": true
        },
        {
            "code": "225100000X",
            "taxonomy_group": "",
            "desc": "Physical Therapist",
            "state": "HI",
            "license": "3843",
            "primary": false
        },
        {
            "code": "225100000X",
            "taxonomy_group": "",
            "desc": "Physical Therapist",
            "state": "DC",
            "license": "871828",
            "primary": false
        },
        {
            "code": "225100000X",
            "taxonomy_group": "",
            "desc": "Physical Therapist",
            "state": "IA",
            "license": "080290",
            "primary": false
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

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• Physical Therapist in Danville, IA
• Providers in Danville, IA by specialty
• Physical Therapist in Iowa

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jun 21, 2016; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.