Healthcare Provider Details

I. General information

NPI: 1760642557
Provider Name (Legal Business Name): BARBARA KINGSLEY SHANLEY PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/15/2008
Last Update Date: 08/14/2026
Certification Date: 08/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

41800 W 11 MILE RD STE 109
NOVI MI
48375-1818
US

IV. Provider business mailing address

419 ROBERTS DR
JONESVILLE MI
49250-9412
US

V. Phone/Fax

Practice location:
  • Phone: 833-578-2763
  • Fax: 989-422-4490
Mailing address:
  • Phone: 734-250-4206
  • Fax: 989-422-4490

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number5601005274
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: