Healthcare Provider Details

I. General information

NPI: 1477984623
Provider Name (Legal Business Name): SHANNON KIMBERLY PAYNE ANP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/12/2013
Last Update Date: 02/17/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2001 S MERRIMAN RD STE 300
WESTLAND MI
48186-5542
US

IV. Provider business mailing address

2001 S MERRIMAN RD STE 300
WESTLAND MI
48186-5542
US

V. Phone/Fax

Practice location:
  • Phone: 734-727-1115
  • Fax:
Mailing address:
  • Phone: 734-727-1115
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number4704220814
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: