Provider Demographics
NPI:1235486077
Name:LUNDQUIST-SHAW, MARTA ELIZABETH
Entity Type:Individual
Prefix:MRS
First Name:MARTA
Middle Name:ELIZABETH
Last Name:LUNDQUIST-SHAW
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 1:11439 FOLEY RD
Mailing Address - Street 2:
Mailing Address - City:FENTON
Mailing Address - State:MI
Mailing Address - Zip Code:48430-9599
Mailing Address - Country:US
Mailing Address - Phone:810-208-0422
Mailing Address - Fax:
Practice Address - Street 1:11439 FOLEY RD
Practice Address - Street 2:
Practice Address - City:FENTON
Practice Address - State:MI
Practice Address - Zip Code:48430-9599
Practice Address - Country:US
Practice Address - Phone:810-208-0422
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-10
Last Update Date:2012-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI11162380174N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174N00000XOther Service ProvidersLactation Consultant, Non-RN