Healthcare Provider Details

I. General information

NPI: 1326567413
Provider Name (Legal Business Name): SHELLY J CARNEVALE RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/11/2017
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

710 KENMOOR AVE SE STE 200
GRAND RAPIDS MI
49546-2379
US

IV. Provider business mailing address

710 KENMOOR AVE SE STE 200
GRAND RAPIDS MI
49546-2379
US

V. Phone/Fax

Practice location:
  • Phone: 616-588-7246
  • Fax:
Mailing address:
  • Phone: 616-588-7246
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number4704230671
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: