1295065951 NPI number — MS. CHRISTINE HOLLY SHANTRY ACNP

Table of content: MS. CHRISTINE HOLLY SHANTRY ACNP (NPI 1295065951)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1295065951 NPI number — MS. CHRISTINE HOLLY SHANTRY ACNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SHANTRY
Provider First Name:
CHRISTINE
Provider Middle Name:
HOLLY
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
ACNP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1295065951
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/24/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
38935 ANN ARBOR RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LIVONIA
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48150-3397
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
734-632-0175
Provider Business Mailing Address Fax Number:
734-632-0182

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
15855 19 MILE RD
Provider Second Line Business Practice Location Address:
EMERGENCY DEPT
Provider Business Practice Location Address City Name:
CLINTON TOWNSHIP
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48038-3504
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
586-263-2601
Provider Business Practice Location Address Fax Number:
586-263-2589
Provider Enumeration Date:
12/31/2009

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LA2100X , with the licence number:  4704226543 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363L00000X , with the licence number: 4704226543 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 12067480 . This is a "CAQH" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




Copyright © 2007-2024 www.npivalidator.com