Provider Demographics
NPI:1861004319
Name:CLARK, SHANA (RN)
Entity Type:Individual
Prefix:
First Name:SHANA
Middle Name:
Last Name:CLARK
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23745 ROCKINGHAM ST
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48033-7025
Mailing Address - Country:US
Mailing Address - Phone:248-242-1193
Mailing Address - Fax:
Practice Address - Street 1:25900 GREENFIELD RD STE 414
Practice Address - Street 2:
Practice Address - City:OAK PARK
Practice Address - State:MI
Practice Address - Zip Code:48237-1267
Practice Address - Country:US
Practice Address - Phone:248-242-1193
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-17
Last Update Date:2020-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704307625163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI8848947Medicaid