Provider Demographics
NPI:1164683827
Name:MULROONEY, SHELLEY N (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:SHELLEY
Middle Name:N
Last Name:MULROONEY
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:1335 CORDOVA CV
Mailing Address - Street 2:DERMATOLOGY EAST
Mailing Address - City:GERMANTOWN
Mailing Address - State:TN
Mailing Address - Zip Code:38138-2200
Mailing Address - Country:US
Mailing Address - Phone:901-753-2794
Mailing Address - Fax:901-753-8876
Practice Address - Street 1:1335 CORDOVA COVE
Practice Address - Street 2:DERMATOLOGY EAST
Practice Address - City:GERMANTOWN
Practice Address - State:TN
Practice Address - Zip Code:38138
Practice Address - Country:US
Practice Address - Phone:901-753-2794
Practice Address - Fax:901-753-8876
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-24
Last Update Date:2016-10-21
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TNPA2212363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1031976532Medicare NSC