Shannon Donnel Macklem, PTA

Primary specialty

Physical Therapy AssistantTaxonomy code 225200000X

License

011003 Issued in AZ

Practice address

191 Swanson Ave Ste 102
Lake Havasu City, AZ 86403-6699

Phone

(928) 855-7880

NPI assigned

Jan 7, 2022

Last updated

Jan 7, 2022By 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 1

Addresses

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Medicare enrollment (NPD)

Not enrolled

State licenses

Practice roles

Locations

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships, National Provider Directory roles and organizations whose NPPES authorized official is this provider.

• Agave Physical Therapy LLC

  • Physical Therapy Clinic/Center
  • Lake Havasu City, AZ
  • NPI 1720521040
  NPD

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

{
    "created_epoch": "1641513600000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1641513600000",
    "number": "1922769272",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "191 SWANSON AVE STE 102",
            "city": "LAKE HAVASU CITY",
            "state": "AZ",
            "postal_code": "864036699",
            "telephone_number": "928-855-7880"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "191 SWANSON AVE STE 102",
            "city": "LAKE HAVASU CITY",
            "state": "AZ",
            "postal_code": "864036699",
            "telephone_number": "928-855-7880"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "MACKLEM",
        "first_name": "SHANNON",
        "middle_name": "DONNEL",
        "credential": "PTA",
        "sole_proprietor": "NO",
        "sex": "F",
        "enumeration_date": "2022-01-07",
        "last_updated": "2022-01-07",
        "certification_date": "2022-01-07",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "225200000X",
            "taxonomy_group": "",
            "desc": "Physical Therapy Assistant",
            "state": "AZ",
            "license": "011003",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Paula R Lupo, MA LPC
• Thomas C Ly, MD
• Jennifer Macdonald
• George Macey
• Nicole Mackey, MS, CCC/A
• Made 4 Movement PLLC
• Maggies Lab Cab, LLC
• Brittney Mahnke, ACNP-AG
• Paul Andrew Mahnke, ACNPC-AG
• Joseph Robert Majerus, DC

• Physical Therapy Assistant in Lake Havasu City, AZ
• Providers in Lake Havasu City, AZ by specialty
• Physical Therapy Assistant in Arizona

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jan 7, 2022; 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.