Provider Demographics
NPI:1568615888
Name:SHANNON, MARQUISA DANAE (BA,MBA)
Entity Type:Individual
Prefix:MS
First Name:MARQUISA
Middle Name:DANAE
Last Name:SHANNON
Suffix:
Gender:F
Credentials:BA,MBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:274 LAKEWOOD ST
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48215-3152
Mailing Address - Country:US
Mailing Address - Phone:313-822-7986
Mailing Address - Fax:
Practice Address - Street 1:4875 COPLIN ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48215-2192
Practice Address - Country:US
Practice Address - Phone:313-822-1135
Practice Address - Fax:313-822-1157
Is Sole Proprietor?:No
Enumeration Date:2008-10-30
Last Update Date:2008-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6803085735247200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other