1053647651 NPI number — MS. SHANNEN MARCIE MITCHELL HIS

Table of content: MS. SHANNEN MARCIE MITCHELL HIS (NPI 1053647651)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1053647651 NPI number — MS. SHANNEN MARCIE MITCHELL HIS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MITCHELL
Provider First Name:
SHANNEN
Provider Middle Name:
MARCIE
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
HIS
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1053647651
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/16/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
400 S HENDERSON ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FT WORTH
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
76104-1017
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
817-335-2583
Provider Business Mailing Address Fax Number:
817-335-2597

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3937 BOAT CLUB RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LAKE WORTH
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
76135-3202
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
817-238-9737
Provider Business Practice Location Address Fax Number:
817-238-9963
Provider Enumeration Date:
11/02/2009

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 237700000X , with the licence number:  80378 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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