MEDICARE: BROOKE WANSHON MS, RN, CPNP-PC

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	363LP0200X	Pediatric Nurse Practitioner	4704296967	MI

General Provider Information

NPI Number	:	1588013973
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BROOKE WANSHON MS, RN, CPNP-PC

Provider Business Mailing Address
First Line	:	11022 HILLCREST ST
Second Line	:
City	:	LIVONIA
State	:	MI
Zip	:	48150-2922
Country	:	US
Telephone Number	:	734-673-1560
Fax Number	:

Provider Business Practice Location Address
First Line	:	2331 MONROE ST
Second Line	:
City	:	DEARBORN
State	:	MI
Zip	:	48124-3009
Country	:	US
Telephone Number	:	734-673-1560
Fax Number	:

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

Provider Enumeration Date	:	06/07/2016
Last Update Date	:	06/07/2016

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