Provider Demographics
NPI:1689918849
Name:MAGO, SHANNA (PMHNP-BC)
Entity Type:Individual
Prefix:
First Name:SHANNA
Middle Name:
Last Name:MAGO
Suffix:
Gender:F
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10440 PARK RD STE 300
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28210-8544
Mailing Address - Country:US
Mailing Address - Phone:980-237-4766
Mailing Address - Fax:980-404-2274
Practice Address - Street 1:10440 PARK RD STE 300
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28210-8544
Practice Address - Country:US
Practice Address - Phone:980-237-4766
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-11-12
Last Update Date:2023-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC18070363L00000X
NC5913661363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner