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General NPI Number Information
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NPI Number | 1508397290
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Entity Type | Individual
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Provider Name | SHANNON MARIE MOONEY CNP
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Gender | Female
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Dates
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Enumeration Date | 03/23/2017
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Last Update Date | 09/16/2019
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Provider Practice Location Address
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Address Line | 45 10TH ST W
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City | SAINT PAUL
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State | MN
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Zip | 55102-1062
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Country | US
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Telephone | 651-326-3800
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Fax |
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Provider Business Mailing Address
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Address Line | 396 LINDA AVE
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City | LINO LAKES
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State | MN
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Zip | 55014-6404
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Country | US
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Telephone | 612-770-4296
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LG0600X
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Taxonomy Name | Gerontology Nurse Practitioner
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License Number | CNP 5045
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License Number State | MN
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