MEDICARE: SHANDA A PICKETT LPN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	164W00000X	Licensed Practical Nurse	4703113183	MI

General Provider Information

NPI Number	:	1316182231
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHANDA A PICKETT LPN

Provider Business Mailing Address
First Line	:	8201 GRANDVILLE AVE
Second Line	:	1
City	:	DETROIT
State	:	MI
Zip	:	48228-3007
Country	:	US
Telephone Number	:	248-818-2862
Fax Number	:

Provider Business Practice Location Address
First Line	:	8201 GRANDVILLE AVE
Second Line	:	1
City	:	DETROIT
State	:	MI
Zip	:	48228-3007
Country	:	US
Telephone Number	:	248-818-2862
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/05/2008
Last Update Date	:	10/25/2014

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Directions to “ SHANDA A PICKETT LPN” Practice Location

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