Provider Demographics
NPI:1407233794
Name:SHABAZZ, ANJULITA
Entity Type:Individual
Prefix:
First Name:ANJULITA
Middle Name:
Last Name:SHABAZZ
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 1:17160 KENTUCKY ST
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48221-2447
Mailing Address - Country:US
Mailing Address - Phone:313-212-5439
Mailing Address - Fax:
Practice Address - Street 1:17160 KENTUCKY ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48221-2447
Practice Address - Country:US
Practice Address - Phone:313-212-5439
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-06
Last Update Date:2015-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4703112792164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse