Healthcare Provider Details

I. General information

NPI: 1558835595
Provider Name (Legal Business Name): SHIRLEY MARIE VICENTE-CASTRO NP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/13/2019
Last Update Date: 07/08/2021
Certification Date: 07/08/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3601 W 13 MILE RD
ROYAL OAK MI
48073-6712
US

IV. Provider business mailing address

500 KIRTS BLVD STE 100
TROY MI
48084-4135
US

V. Phone/Fax

Practice location:
  • Phone: 248-577-9700
  • Fax:
Mailing address:
  • Phone: 248-434-6169
  • Fax: 855-618-6655

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number4704308074
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number4704308074
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: