Provider Demographics
NPI:1275161275
Name:SHAUGHNESSY, MACKENZIE R (DO)
Entity Type:Individual
Prefix:DR
First Name:MACKENZIE
Middle Name:R
Last Name:SHAUGHNESSY
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5000 E MARKET ST STE 30
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:OH
Mailing Address - Zip Code:44484-2259
Mailing Address - Country:US
Mailing Address - Phone:330-856-9699
Mailing Address - Fax:
Practice Address - Street 1:5000 E MARKET ST STE 30
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:OH
Practice Address - Zip Code:44484-2259
Practice Address - Country:US
Practice Address - Phone:330-856-9699
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-27
Last Update Date:2023-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
OH34.016571208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program