Provider Demographics
NPI:1376158311
Name:SHAFFER, HAVEN
Entity Type:Individual
Prefix:
First Name:HAVEN
Middle Name:
Last Name:SHAFFER
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 1:1052 N MONROE ST
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:MI
Mailing Address - Zip Code:48162
Mailing Address - Country:US
Mailing Address - Phone:734-242-9550
Mailing Address - Fax:
Practice Address - Street 1:1502 N MONROE ST.
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:MI
Practice Address - Zip Code:48162
Practice Address - Country:US
Practice Address - Phone:734-242-9550
Practice Address - Fax:734-971-2303
Is Sole Proprietor?:No
Enumeration Date:2020-09-15
Last Update Date:2021-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704329812363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics