Provider Demographics
NPI:1689177313
Name:ANGLE, SHAUNTELLE DOMINIQUE
Entity Type:Individual
Prefix:
First Name:SHAUNTELLE
Middle Name:DOMINIQUE
Last Name:ANGLE
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 1:3087 WOODCREEK WAY
Mailing Address - Street 2:
Mailing Address - City:BLOOMFIELD HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48304-1864
Mailing Address - Country:US
Mailing Address - Phone:586-549-4565
Mailing Address - Fax:248-481-2858
Practice Address - Street 1:75 BARCLAY CIR
Practice Address - Street 2:
Practice Address - City:ROCHESTER HILLS
Practice Address - State:MI
Practice Address - Zip Code:48307-5820
Practice Address - Country:US
Practice Address - Phone:248-856-6300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-08
Last Update Date:2018-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704277472363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily