Healthcare Provider Details

I. General information

NPI: 1275982886
Provider Name (Legal Business Name): MRS. SHANNON BLANK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/06/2016
Last Update Date: 06/06/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1382 W B AVE
PLAINWELL MI
49080-9685
US

IV. Provider business mailing address

1382 W B AVE
PLAINWELL MI
49080-9685
US

V. Phone/Fax

Practice location:
  • Phone: 616-405-5992
  • Fax:
Mailing address:
  • Phone: 616-405-5992
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code247200000X
TaxonomyOther Technician
License NumberS530765069584
License Number StateMI

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: