Healthcare Provider Details

I. General information

NPI: 1487136552
Provider Name (Legal Business Name): SHAWNA SUSANNE CUDA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/05/2018
Last Update Date: 03/04/2020
Certification Date: 03/04/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1428 S LAPEER RD
LAKE ORION MI
48360-1437
US

IV. Provider business mailing address

1428 S LAPEER RD
LAKE ORION MI
48360-1437
US

V. Phone/Fax

Practice location:
  • Phone: 248-693-0543
  • Fax: 248-693-3683
Mailing address:
  • Phone: 248-693-0543
  • Fax: 248-693-3683

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number4704293145
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: