Healthcare Provider Details

I. General information

NPI: 1821137829
Provider Name (Legal Business Name): SHANNON SMITH NNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/06/2007
Last Update Date: 01/19/2021
Certification Date: 01/19/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6777 W MAPLE RD DEPARTMENT OF WOMENS HEALTH
WEST BLOOMFIELD MI
48322-3013
US

IV. Provider business mailing address

26901 BEAUMONT BLVD
SOUTHFIELD MI
48033-3849
US

V. Phone/Fax

Practice location:
  • Phone: 313-874-4688
  • Fax:
Mailing address:
  • Phone: 248-577-3313
  • Fax: 248-577-3302

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LN0000X
TaxonomyNeonatal Nurse Practitioner
License Number4704216593
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: