1184991713 NPI number — SHANNON KONIECZKI RN, MSN, CPNP

Table of content: SHANNON KONIECZKI RN, MSN, CPNP (NPI 1184991713)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1184991713 NPI number — SHANNON KONIECZKI RN, MSN, CPNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KONIECZKI
Provider First Name:
SHANNON
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
RN, MSN, CPNP
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:
1184991713
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/27/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4201 ST. ANTIONE UHC 5D
Provider Second Line Business Mailing Address:
UNIVERDITY PEDIATRICIANS
Provider Business Mailing Address City Name:
DETROIT
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48201-2119
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
313-966-5051
Provider Business Mailing Address Fax Number:
313-966-0665

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3901 BEAUBIEN ST.
Provider Second Line Business Practice Location Address:
CHILDREN'S HOSPITAL OF MI
Provider Business Practice Location Address City Name:
DETROIT
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48201-2119
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
313-993-2950
Provider Business Practice Location Address Fax Number:
313-745-5237
Provider Enumeration Date:
11/28/2011

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: 363LP0200X , with the licence number:  4704261113 , 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)





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