MEDICARE: SHANNA E COOK PHLEBOTOMIST SPECIAL

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy	License Number State
1	174400000X	Specialist	MI
2	246QL0900X	Laboratory Management Specialist/Technologist	MI
3	343900000X	Non-emergency Medical Transport (VAN)	MI
4	246RP1900X	Phlebotomy Technician	MI

General Provider Information

NPI Number	:	1871064808
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHANNA E COOK PHLEBOTOMIST SPECIAL

Provider Business Mailing Address
First Line	:	20843 GARDEN LN
Second Line	:
City	:	FERNDALE
State	:	MI
Zip	:	48220-2217
Country	:	US
Telephone Number	:	248-506-7849
Fax Number	:

Provider Business Practice Location Address
First Line	:	20843 GARDEN LN
Second Line	:
City	:	FERNDALE
State	:	MI
Zip	:	48220-2217
Country	:	US
Telephone Number	:	248-506-7849
Fax Number	:

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

Provider Enumeration Date	:	12/17/2018
Last Update Date	:	12/17/2018

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