Provider Demographics
NPI:1710606314
Name:SHANNON, CHANDELLE EILENE (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:CHANDELLE
Middle Name:EILENE
Last Name:SHANNON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:CHANDELLE
Other - Middle Name:EILENE
Other - Last Name:KELLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:3265 FIVE POINTS DR
Mailing Address - Street 2:
Mailing Address - City:AUBURN HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48326-2337
Mailing Address - Country:US
Mailing Address - Phone:248-609-1234
Mailing Address - Fax:248-290-9643
Practice Address - Street 1:3265 FIVE POINTS DR STE A
Practice Address - Street 2:
Practice Address - City:AUBURN HILLS
Practice Address - State:MI
Practice Address - Zip Code:48326-2337
Practice Address - Country:US
Practice Address - Phone:248-609-1234
Practice Address - Fax:248-290-9643
Is Sole Proprietor?:No
Enumeration Date:2022-08-25
Last Update Date:2023-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI1191042363AM0700X
MI5601011252363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical