Provider Demographics
NPI:1144771379
Name:MARCETIC, SHANNON
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:MARCETIC
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 1:2419 RIVERSIDE DR APT C102
Mailing Address - Street 2:
Mailing Address - City:TRENTON
Mailing Address - State:MI
Mailing Address - Zip Code:48183-2754
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9315 TELEGRAPH RD
Practice Address - Street 2:
Practice Address - City:REDFORD
Practice Address - State:MI
Practice Address - Zip Code:48239-1260
Practice Address - Country:US
Practice Address - Phone:313-450-4500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-24
Last Update Date:2021-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704313073163W00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse