Provider Demographics
NPI:1750932018
Name:SHINNICK, MARY ANN (PHD, ACNP, CNS)
Entity type:Individual
Prefix:DR
First Name:MARY
Middle Name:ANN
Last Name:SHINNICK
Suffix:
Gender:F
Credentials:PHD, ACNP, CNS
Other - Prefix:
Other - First Name:MARY ANN
Other - Middle Name:
Other - Last Name:SHINNICK-WURMSDOBLER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:RN, NP
Mailing Address - Street 1:1110 ARNO DR
Mailing Address - Street 2:
Mailing Address - City:SIERRA MADRE
Mailing Address - State:CA
Mailing Address - Zip Code:91024-1511
Mailing Address - Country:US
Mailing Address - Phone:626-991-2912
Mailing Address - Fax:
Practice Address - Street 1:1110 ARNO DR
Practice Address - Street 2:
Practice Address - City:SIERRA MADRE
Practice Address - State:CA
Practice Address - Zip Code:91024-1511
Practice Address - Country:US
Practice Address - Phone:626-991-2912
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-26
Last Update Date:2019-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA8478363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA8478OtherCALIFORNIA NP FURNISHING NUMBER
CA8478OtherNP FURNISHING NUMBER