Healthcare Provider Details

I. General information

NPI: 1063166320
Provider Name (Legal Business Name): KARA LYNN SHALL
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/07/2022
Last Update Date: 02/07/2022
Certification Date: 02/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

656 LINCOLN RD
GROSSE POINTE MI
48230-1220
US

IV. Provider business mailing address

656 LINCOLN RD
GROSSE POINTE MI
48230-1220
US

V. Phone/Fax

Practice location:
  • Phone: 313-330-0795
  • Fax:
Mailing address:
  • Phone: 313-330-0795
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: