Provider Demographics
NPI:1588670111
Name:SHANNON, NANCY JEAN (MD, PHD)
Entity Type:Individual
Prefix:DR
First Name:NANCY
Middle Name:JEAN
Last Name:SHANNON
Suffix:
Gender:F
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6150 SHOEMAN RD
Mailing Address - Street 2:
Mailing Address - City:HASLETT
Mailing Address - State:MI
Mailing Address - Zip Code:48840-9110
Mailing Address - Country:US
Mailing Address - Phone:517-339-4107
Mailing Address - Fax:517-339-4332
Practice Address - Street 1:1650 HASLETT RD
Practice Address - Street 2:SUITE 1
Practice Address - City:HASLETT
Practice Address - State:MI
Practice Address - Zip Code:48840-8438
Practice Address - Country:US
Practice Address - Phone:517-339-4107
Practice Address - Fax:517-339-4336
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MINS073455207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4526871Medicaid
MI4526871Medicaid
MI0N77020Medicare ID - Type Unspecified