Healthcare Provider Details

I. General information

NPI: 1497614168
Provider Name (Legal Business Name): SHANNON NICOLE KAYE ORTIZ ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/19/2026
Last Update Date: 05/07/2026
Certification Date: 05/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15520 19 MILE RD STE 450
CLINTON TWP MI
48038-6332
US

IV. Provider business mailing address

33900 HARPER AVE STE 104
CLINTON TWP MI
48035-4258
US

V. Phone/Fax

Practice location:
  • Phone: 586-416-2000
  • Fax: 586-416-2013
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number2601003228
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: