Provider Demographics
NPI:1851659064
Name:SHATTUCK, BRANDY LYNNE (M D)
Entity Type:Individual
Prefix:
First Name:BRANDY
Middle Name:LYNNE
Last Name:SHATTUCK
Suffix:
Gender:F
Credentials:M D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4000 MOUNTAIN GLADE DR
Mailing Address - Street 2:APARTMENT 4
Mailing Address - City:HOLT
Mailing Address - State:MI
Mailing Address - Zip Code:48842-7738
Mailing Address - Country:US
Mailing Address - Phone:518-542-1097
Mailing Address - Fax:
Practice Address - Street 1:1322 E MICHIGAN AVE
Practice Address - Street 2:
Practice Address - City:LANSING
Practice Address - State:MI
Practice Address - Zip Code:48912-2199
Practice Address - Country:US
Practice Address - Phone:517-364-3963
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-04-25
Last Update Date:2013-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301097773207ZF0201X, 207ZP0102X
MO2012019898207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZF0201XAllopathic & Osteopathic PhysiciansPathologyForensic Pathology
No207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO152360615Medicare UPIN