Healthcare Provider Details

I. General information

NPI: 1801719604
Provider Name (Legal Business Name): SHONDANIQUE WHITESIDE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/30/2026
Last Update Date: 07/30/2026
Certification Date: 07/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19501 DRESDEN ST
DETROIT MI
48205-1624
US

IV. Provider business mailing address

19501 DRESDEN ST
DETROIT MI
48205-1624
US

V. Phone/Fax

Practice location:
  • Phone: 313-980-9953
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332U00000X
TaxonomyHome Delivered Meals
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: