MEDICARE: SHANTIQUE DORTCH

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	164W00000X	Licensed Practical Nurse	4703117952	MI

General Provider Information

NPI Number	:	1144706169
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHANTIQUE DORTCH

Provider Business Mailing Address
First Line	:	39449 DELLA ROSA DR
Second Line	:
City	:	STERLING HEIGHTS
State	:	MI
Zip	:	48313-5227
Country	:	US
Telephone Number	:	313-870-8736
Fax Number	:

Provider Business Practice Location Address
First Line	:	39449 DELLA ROSA DR
Second Line	:
City	:	STERLING HEIGHTS
State	:	MI
Zip	:	48313-5227
Country	:	US
Telephone Number	:	313-870-8736
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/12/2018
Last Update Date	:	04/14/2022

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