Provider Demographics
NPI:1003325895
Name:SMITH, SHONNA SHANEICE (RN)
Entity Type:Individual
Prefix:MS
First Name:SHONNA
Middle Name:SHANEICE
Last Name:SMITH
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1908 S BURDICK ST
Mailing Address - Street 2:
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49001-3626
Mailing Address - Country:US
Mailing Address - Phone:269-217-3108
Mailing Address - Fax:
Practice Address - Street 1:615 E CROSSTOWN PKWY
Practice Address - Street 2:
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49001-2501
Practice Address - Country:US
Practice Address - Phone:269-553-7037
Practice Address - Fax:269-382-0019
Is Sole Proprietor?:No
Enumeration Date:2017-09-25
Last Update Date:2017-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704298740163WP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health