Provider Demographics
NPI:1710590765
Name:MULDOON, SHANNON
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:MULDOON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:50 WANDA ST APT 4
Mailing Address - Street 2:
Mailing Address - City:NARRAGANSETT
Mailing Address - State:RI
Mailing Address - Zip Code:02882-3335
Mailing Address - Country:US
Mailing Address - Phone:401-862-7167
Mailing Address - Fax:
Practice Address - Street 1:25 WELLS ST
Practice Address - Street 2:
Practice Address - City:WESTERLY
Practice Address - State:RI
Practice Address - Zip Code:02891-2922
Practice Address - Country:US
Practice Address - Phone:401-596-6000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-28
Last Update Date:2020-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RISP01419235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist