Provider Demographics
NPI:1053815274
Name:MICHEL WYNN, SHANNON ELIZABETH (MD)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:ELIZABETH
Last Name:MICHEL WYNN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:SHANNON
Other - Middle Name:ELIZABETH
Other - Last Name:MICHEL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:24 HOSPITAL AVE
Mailing Address - Street 2:
Mailing Address - City:DANBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06810-6077
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:24 HOSPITAL AVE
Practice Address - Street 2:
Practice Address - City:DANBURY
Practice Address - State:CT
Practice Address - Zip Code:06810-6099
Practice Address - Country:US
Practice Address - Phone:203-739-7000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-21
Last Update Date:2023-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT74367207RH0002X, 2080H0002X
OH35144996207RH0002X, 2080H0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080H0002XAllopathic & Osteopathic PhysiciansPediatricsHospice and Palliative Medicine
No207RH0002XAllopathic & Osteopathic PhysiciansInternal MedicineHospice and Palliative Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL125.071869OtherDEPARTMENT OF FINANCIAL AND PROFESSIONAL REGULATION