Provider Demographics
NPI:1326549148
Name:DAVIS, SHENICAK KUJUANA
Entity Type:Individual
Prefix:
First Name:SHENICAK
Middle Name:KUJUANA
Last Name:DAVIS
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 1:16434 CONSTANCE AVE
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48228-4311
Mailing Address - Country:US
Mailing Address - Phone:313-455-2910
Mailing Address - Fax:
Practice Address - Street 1:16434 CONSTANCE AVE
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48228-4311
Practice Address - Country:US
Practice Address - Phone:313-455-2910
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-27
Last Update Date:2018-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI106S00000X, 3747A0650X
3747A0650X, 3747P1801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI824451938OtherMCPN'S
MI82-4451938Medicaid
824451938OtherDIFFERENT NETWORKS
MI82-4451938OtherCLS
MI844451938Medicaid