Provider Demographics
NPI:1114620226
Name:MUGNO, SHANNA (MD)
Entity Type:Individual
Prefix:MRS
First Name:SHANNA
Middle Name:
Last Name:MUGNO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:SHANNA
Other - Middle Name:
Other - Last Name:FITZPATRICK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:3876 LAWRENCE RD
Mailing Address - Street 2:
Mailing Address - City:SEAFORD
Mailing Address - State:NY
Mailing Address - Zip Code:11783-1212
Mailing Address - Country:US
Mailing Address - Phone:613-335-2217
Mailing Address - Fax:
Practice Address - Street 1:3876 LAWRENCE RD
Practice Address - Street 2:
Practice Address - City:SEAFORD
Practice Address - State:NY
Practice Address - Zip Code:11783-1212
Practice Address - Country:US
Practice Address - Phone:613-335-2217
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-27
Last Update Date:2023-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY607926051222Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist