Healthcare Provider Details

I. General information

NPI: 1750781514
Provider Name (Legal Business Name): SHANNON MULLIS CNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/29/2014
Last Update Date: 09/30/2026
Certification Date: 09/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6191 SHEED RD
CINCINNATI OH
45247-3602
US

IV. Provider business mailing address

6191 SHEED RD
CINCINNATI OH
45247-3602
US

V. Phone/Fax

Practice location:
  • Phone: 999-999-9999
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License NumberAPRN.CNP.16422
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number3008903
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: