Provider Demographics
NPI:1144750654
Name:FRAZIER, SHATINA
Entity Type:Individual
Prefix:
First Name:SHATINA
Middle Name:
Last Name:FRAZIER
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 1:29600 FRANKLIN RD.
Mailing Address - Street 2:#18
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48034
Mailing Address - Country:US
Mailing Address - Phone:248-923-1234
Mailing Address - Fax:
Practice Address - Street 1:20000 PIERSON ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48219-1310
Practice Address - Country:US
Practice Address - Phone:248-818-4326
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-16
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4703113652164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2488184326Medicaid