Provider Demographics
NPI:1790313476
Name:MULLES, SHANEN M (MD)
Entity Type:Individual
Prefix:DR
First Name:SHANEN
Middle Name:M
Last Name:MULLES
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:HSC LEVEL 19, ROOM 030
Mailing Address - Street 2:
Mailing Address - City:STONY BROOK
Mailing Address - State:NY
Mailing Address - Zip Code:11794-8191
Mailing Address - Country:US
Mailing Address - Phone:631-444-1791
Mailing Address - Fax:631-444-7689
Practice Address - Street 1:HSC LEVEL 19, ROOM 030
Practice Address - Street 2:
Practice Address - City:STONY BROOK
Practice Address - State:NY
Practice Address - Zip Code:11794-8191
Practice Address - Country:US
Practice Address - Phone:631-444-1791
Practice Address - Fax:631-444-7689
Is Sole Proprietor?:No
Enumeration Date:2020-03-30
Last Update Date:2020-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program