Healthcare Provider Details

I. General information

NPI: 1851712319
Provider Name (Legal Business Name): SHANNAN KLINE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/30/2013
Last Update Date: 12/30/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

724 W CENTRE AVE STE 105
PORTAGE MI
49024-6306
US

IV. Provider business mailing address

5084 LOVERS LN
PORTAGE MI
49002-1557
US

V. Phone/Fax

Practice location:
  • Phone: 269-327-3700
  • Fax: 269-323-0229
Mailing address:
  • Phone: 269-327-3700
  • Fax: 269-323-0229

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code173000000X
TaxonomyLegal Medicine
License Number4301068834
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: