Provider Demographics
NPI:1477917169
Name:KRYLA, SHANNON RAE
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:RAE
Last Name:KRYLA
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 1:48 GINGELL CT
Mailing Address - Street 2:
Mailing Address - City:PONTIAC
Mailing Address - State:MI
Mailing Address - Zip Code:48342
Mailing Address - Country:US
Mailing Address - Phone:248-421-7253
Mailing Address - Fax:
Practice Address - Street 1:1060 W SILVERBELL RD
Practice Address - Street 2:
Practice Address - City:LAKE ORION
Practice Address - State:MI
Practice Address - Zip Code:48359-1327
Practice Address - Country:US
Practice Address - Phone:248-845-4082
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-08
Last Update Date:2016-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI3501002943174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist