Healthcare Provider Details

I. General information

NPI: 1962200360
Provider Name (Legal Business Name): CODY W SHIPLEY PMHNP-BC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/04/2025
Last Update Date: 03/04/2025
Certification Date: 03/04/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

818 PARIS AVE NE
GRAND RAPIDS MI
49503-1753
US

IV. Provider business mailing address

818 PARIS AVE NE
GRAND RAPIDS MI
49503-1753
US

V. Phone/Fax

Practice location:
  • Phone: 214-728-5982
  • Fax:
Mailing address:
  • Phone: 214-728-5982
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number4704355672
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: