Provider Demographics
NPI:1316182231
Name:PICKETT, SHANDA A (LPN)
Entity Type:Individual
Prefix:
First Name:SHANDA
Middle Name:A
Last Name:PICKETT
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8201 GRANDVILLE AVE
Mailing Address - Street 2:1
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48228-3007
Mailing Address - Country:US
Mailing Address - Phone:248-818-2862
Mailing Address - Fax:
Practice Address - Street 1:8201 GRANDVILLE AVE
Practice Address - Street 2:1
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48228-3007
Practice Address - Country:US
Practice Address - Phone:248-818-2862
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-12-05
Last Update Date:2014-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4703113183164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse