Provider Demographics
NPI:1780181743
Name:MIMNAUGH, SHANNON LEIGH ANNE (DO)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:LEIGH ANNE
Last Name:MIMNAUGH
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 1:1100 WESCOTT DR STE 101
Mailing Address - Street 2:
Mailing Address - City:FLEMINGTON
Mailing Address - State:NJ
Mailing Address - Zip Code:08822-4600
Mailing Address - Country:US
Mailing Address - Phone:908-788-6535
Mailing Address - Fax:
Practice Address - Street 1:1100 WESCOTT DR STE 101
Practice Address - Street 2:
Practice Address - City:FLEMINGTON
Practice Address - State:NJ
Practice Address - Zip Code:08822-4600
Practice Address - Country:US
Practice Address - Phone:908-788-6535
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-06
Last Update Date:2021-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MB10958200207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine