Provider Demographics
NPI:1710112891
Name:DANNARD, SHARON MARIE (OTR)
Entity Type:Individual
Prefix:MS
First Name:SHARON
Middle Name:MARIE
Last Name:DANNARD
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15469 WHITCOMB ST
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48227-2664
Mailing Address - Country:US
Mailing Address - Phone:313-837-3169
Mailing Address - Fax:313-837-3169
Practice Address - Street 1:15469 WHITCOMB ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48227-2664
Practice Address - Country:US
Practice Address - Phone:313-837-3169
Practice Address - Fax:313-837-3169
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-19
Last Update Date:2009-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5201001602172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI450221Medicaid
MI450221Medicaid
MI450221Medicare PIN
MI450221Medicare UPIN