Healthcare Provider Details

I. General information

NPI: 1821908039
Provider Name (Legal Business Name): SHELBY KIENAST PA-C
Entity Type: Individual
Gender:
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/09/2026
Last Update Date: 09/09/2026
Certification Date: 09/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1057 SUNCREST DR
LAPEER MI
48446-4404
US

IV. Provider business mailing address

1057 SUNCREST DR
LAPEER MI
48446-4404
US

V. Phone/Fax

Practice location:
  • Phone: 810-245-9380
  • Fax:
Mailing address:
  • Phone: 810-245-9380
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number5601014096
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: