Healthcare Provider Details

I. General information

NPI: 1205748944
Provider Name (Legal Business Name): SHYANN LEE TRAYLOR
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/18/2026
Last Update Date: 09/18/2026
Certification Date: 09/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 W SAINT JOSEPH ST
COLOMA MI
49038-9594
US

IV. Provider business mailing address

3541 RED ARROW HWY
BENTON HARBOR MI
49022-9543
US

V. Phone/Fax

Practice location:
  • Phone: 269-248-2400
  • Fax:
Mailing address:
  • Phone: 269-468-2400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: