Provider Demographics
NPI:1710453832
Name:MOLLENKOPF, SHANNON MARIE (NP)
Entity Type:Individual
Prefix:MRS
First Name:SHANNON
Middle Name:MARIE
Last Name:MOLLENKOPF
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4133 BOARDMAN CANFIELD RD
Mailing Address - Street 2:
Mailing Address - City:CANFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:44406-9047
Mailing Address - Country:US
Mailing Address - Phone:330-702-5437
Mailing Address - Fax:330-702-8684
Practice Address - Street 1:4133 BOARDMAN CANFIELD RD
Practice Address - Street 2:
Practice Address - City:CANFIELD
Practice Address - State:OH
Practice Address - Zip Code:44406-9047
Practice Address - Country:US
Practice Address - Phone:330-702-5437
Practice Address - Fax:330-702-8684
Is Sole Proprietor?:No
Enumeration Date:2018-10-16
Last Update Date:2018-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAPRN.CNP.023776208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics