Provider Demographics
NPI:1235788001
Name:MIKITA, SHANNON RAE (RN-BC)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:RAE
Last Name:MIKITA
Suffix:
Gender:F
Credentials:RN-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11279 PERRY HWY STE 204
Mailing Address - Street 2:
Mailing Address - City:WEXFORD
Mailing Address - State:PA
Mailing Address - Zip Code:15090-9303
Mailing Address - Country:US
Mailing Address - Phone:724-933-3910
Mailing Address - Fax:
Practice Address - Street 1:11279 PERRY HWY STE 204
Practice Address - Street 2:
Practice Address - City:WEXFORD
Practice Address - State:PA
Practice Address - Zip Code:15090-9303
Practice Address - Country:US
Practice Address - Phone:724-933-3910
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-05
Last Update Date:2019-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARN609684163WP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health