Provider Demographics
NPI:1497211338
Name:ANTONUCCI, SHELLEY (NURSE PRACTITIONER)
Entity Type:Individual
Prefix:MS
First Name:SHELLEY
Middle Name:
Last Name:ANTONUCCI
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:355 TYLER ROAD
Mailing Address - Street 2:
Mailing Address - City:LASALLE
Mailing Address - State:ONTARIO
Mailing Address - Zip Code:N9J3X2
Mailing Address - Country:CA
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:17187 SCHAEFER HWY
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48235-4132
Practice Address - Country:US
Practice Address - Phone:313-960-6605
Practice Address - Fax:248-595-8269
Is Sole Proprietor?:No
Enumeration Date:2019-02-15
Last Update Date:2019-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704261629363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner