Provider Demographics
NPI:1689026973
Name:WALSH, SHANNON TAYLOR
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:TAYLOR
Last Name:WALSH
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 1:8602 RAVINE DR
Mailing Address - Street 2:
Mailing Address - City:WESTLAND
Mailing Address - State:MI
Mailing Address - Zip Code:48185-1336
Mailing Address - Country:US
Mailing Address - Phone:734-421-5122
Mailing Address - Fax:
Practice Address - Street 1:8602 RAVINE DR
Practice Address - Street 2:
Practice Address - City:WESTLAND
Practice Address - State:MI
Practice Address - Zip Code:48185-1336
Practice Address - Country:US
Practice Address - Phone:734-421-5122
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-07-11
Last Update Date:2016-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other