Healthcare Provider Details

I. General information

NPI: 1679041545
Provider Name (Legal Business Name): SHIBA LASHON NIXON PMHNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/08/2018
Last Update Date: 12/05/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

NEW OAKLAND 6549 TOWN CENTER SUITE A
CLARKSTON MI
48346
US

IV. Provider business mailing address

29781 SPRING HILL DR
SOUTHFIELD MI
48076-1859
US

V. Phone/Fax

Practice location:
  • Phone: 248-620-6400
  • Fax: 248-620-6405
Mailing address:
  • Phone: 313-550-9605
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License Number4704264372
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number4704264372
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: