Provider Demographics
NPI:1891171021
Name:MULLEN, SHANNON K (RN)
Entity Type:Individual
Prefix:MS
First Name:SHANNON
Middle Name:K
Last Name:MULLEN
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:653 EAST 6TH. ST.
Mailing Address - Street 2:
Mailing Address - City:SOUTH BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02127
Mailing Address - Country:US
Mailing Address - Phone:617-803-0396
Mailing Address - Fax:
Practice Address - Street 1:20 THELMA RD
Practice Address - Street 2:
Practice Address - City:DORCHESTER
Practice Address - State:MA
Practice Address - Zip Code:02122
Practice Address - Country:US
Practice Address - Phone:617-938-0228
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-08-11
Last Update Date:2015-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN2277686163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse