Provider Demographics
NPI:1750162814
Name:MINNICK, SHAUNNA F (RN)
Entity type:Individual
Prefix:
First Name:SHAUNNA
Middle Name:F
Last Name:MINNICK
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 1:5907 COVINGTON RD STE E
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46804-5867
Mailing Address - Country:US
Mailing Address - Phone:317-650-9031
Mailing Address - Fax:
Practice Address - Street 1:5907 COVINGTON RD STE E
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46804-5867
Practice Address - Country:US
Practice Address - Phone:317-650-9031
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-13
Last Update Date:2023-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28213789A163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse