Provider Demographics
NPI:1710066139
Name:NANCY J SHANNON MD PHD PLLC
Entity Type:Organization
Organization Name:NANCY J SHANNON MD PHD PLLC
Other - Org Name:ADVANCED HEALTH & IMAGE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:NANCY
Authorized Official - Middle Name:J
Authorized Official - Last Name:SHANNON
Authorized Official - Suffix:
Authorized Official - Credentials:MD, PHD
Authorized Official - Phone:517-339-4107
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:517-339-4322
Practice Address - Street 1:1650 HASLETT RD
Practice Address - Street 2:
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:517-339-4322
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-05
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MINS073455261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center