Healthcare Provider Details

I. General information

NPI: 1154135564
Provider Name (Legal Business Name): SHOSHANNA LEONA GEFTOS LPN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/05/2025
Last Update Date: 02/05/2025
Certification Date: 02/05/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3250 N MONROE ST STE 2
MONROE MI
48162-9297
US

IV. Provider business mailing address

4982 SYCAMORE RD
NEWPORT MI
48166-9015
US

V. Phone/Fax

Practice location:
  • Phone: 734-384-3121
  • Fax:
Mailing address:
  • Phone: 734-790-1923
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number4703122553
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: