Healthcare Provider Details

I. General information

NPI: 1053251470
Provider Name (Legal Business Name): SHAWN O'MALLEY
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/30/2026
Last Update Date: 03/30/2026
Certification Date: 03/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5333 MCAULEY DR RM 4001
YPSILANTI MI
48197-1099
US

IV. Provider business mailing address

6028 GABRIELLE AVE
ANN ARBOR MI
48103-9839
US

V. Phone/Fax

Practice location:
  • Phone: 734-712-3980
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: