Healthcare Provider Details

I. General information

NPI: 1962625012
Provider Name (Legal Business Name): SHANNON MARIE TOKARSKI MS, RD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SHANNON BLOODWORTH

II. Dates (important events)

Enumeration Date: 04/10/2007
Last Update Date: 03/31/2025
Certification Date: 03/31/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

31214 KENWOOD AVE
MADISON HEIGHTS MI
48071-1082
US

IV. Provider business mailing address

31214 KENWOOD AVE
MADISON HEIGHTS MI
48071-1082
US

V. Phone/Fax

Practice location:
  • Phone: 586-823-4577
  • Fax:
Mailing address:
  • Phone: 586-823-4577
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number925835
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: