Provider Demographics
NPI:1063891166
Name:MUMMA, SHANNON NICOLE (MD)
Entity type:Individual
Prefix:DR
First Name:SHANNON
Middle Name:NICOLE
Last Name:MUMMA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:DEPARTMENT OF EMERGENCY MEDICINE
Mailing Address - Street 2:MEDICAL CENTER BLVD.
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27157-1089
Mailing Address - Country:US
Mailing Address - Phone:336-716-4625
Mailing Address - Fax:
Practice Address - Street 1:DEPARTMENT OF EMERGENCY MEDICINE
Practice Address - Street 2:MEDICAL CENTER BLVD.
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27157-1089
Practice Address - Country:US
Practice Address - Phone:336-716-4625
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-05-21
Last Update Date:2019-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2018-00358207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine