Provider Demographics
NPI:1477984623
Name:PAYNE, SHANNON KIMBERLY (ANP-BC)
Entity Type:Individual
Prefix:MRS
First Name:SHANNON
Middle Name:KIMBERLY
Last Name:PAYNE
Suffix:
Gender:F
Credentials:ANP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2001 S MERRIMAN RD STE 300
Mailing Address - Street 2:
Mailing Address - City:WESTLAND
Mailing Address - State:MI
Mailing Address - Zip Code:48186-5542
Mailing Address - Country:US
Mailing Address - Phone:734-727-1115
Mailing Address - Fax:
Practice Address - Street 1:2001 S MERRIMAN RD STE 300
Practice Address - Street 2:
Practice Address - City:WESTLAND
Practice Address - State:MI
Practice Address - Zip Code:48186-5542
Practice Address - Country:US
Practice Address - Phone:734-727-1115
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-12-12
Last Update Date:2014-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704220814363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health