Provider Demographics
NPI:1891181459
Name:MULLINS, SHANNON RAE (RN)
Entity Type:Individual
Prefix:MRS
First Name:SHANNON
Middle Name:RAE
Last Name:MULLINS
Suffix:
Gender:F
Credentials:RN
Other - Prefix:MS
Other - First Name:SHANNON
Other - Middle Name:RAE
Other - Last Name:MUNDINGER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:2254 IMPERIAL LN
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54302
Mailing Address - Country:US
Mailing Address - Phone:715-661-2206
Mailing Address - Fax:
Practice Address - Street 1:2254 IMPERIAL LN
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54302
Practice Address - Country:US
Practice Address - Phone:715-661-2206
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-04-10
Last Update Date:2015-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI176886164W00000X, 163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No164W00000XNursing Service ProvidersLicensed Practical Nurse