Provider Demographics
NPI:1942653654
Name:SHAMBLIN, JEANE
Entity Type:Individual
Prefix:
First Name:JEANE
Middle Name:
Last Name:SHAMBLIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26722 STANFORD DR W
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48033-6133
Mailing Address - Country:US
Mailing Address - Phone:313-656-7715
Mailing Address - Fax:
Practice Address - Street 1:26722 STANFORD DR W
Practice Address - Street 2:
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48033-6133
Practice Address - Country:US
Practice Address - Phone:313-656-7715
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-07-18
Last Update Date:2016-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4703092663164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse