Healthcare Provider Details

I. General information

NPI: 1538995022
Provider Name (Legal Business Name): AYAH SHKOUKANI
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/11/2024
Last Update Date: 09/11/2024
Certification Date: 09/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15990 W 9 MILE RD
SOUTHFIELD MI
48075-4826
US

IV. Provider business mailing address

33462 ROYAL PARK DR
FRASER MI
48026-5266
US

V. Phone/Fax

Practice location:
  • Phone: 248-559-7958
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number5601012591
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: