Healthcare Provider Details

I. General information

NPI: 1700377132
Provider Name (Legal Business Name): SHANTINIQUE EVANS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/22/2018
Last Update Date: 07/30/2026
Certification Date: 07/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

245 PITKIN ST
HIGHLAND PARK MI
48203-3737
US

IV. Provider business mailing address

14435 FAIRMOUNT DR
DETROIT MI
48205-1273
US

V. Phone/Fax

Practice location:
  • Phone: 313-865-1500
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number4703121742
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: