Provider Demographics
NPI:1033728910
Name:COLE, SHANNON R
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:R
Last Name:COLE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:310 GLOCHESKI DR
Mailing Address - Street 2:
Mailing Address - City:MANISTEE
Mailing Address - State:MI
Mailing Address - Zip Code:49660-2639
Mailing Address - Country:US
Mailing Address - Phone:800-398-2013
Mailing Address - Fax:231-723-1504
Practice Address - Street 1:2198 US 31 S
Practice Address - Street 2:
Practice Address - City:MANISTEE
Practice Address - State:MI
Practice Address - Zip Code:49660-9618
Practice Address - Country:US
Practice Address - Phone:800-398-2013
Practice Address - Fax:231-723-1504
Is Sole Proprietor?:No
Enumeration Date:2020-07-28
Last Update Date:2020-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704317473163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse