Provider Demographics
NPI:1104317544
Name:THODE, SHANAN
Entity type:Individual
Prefix:
First Name:SHANAN
Middle Name:
Last Name:THODE
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 1:630 GRAMPIAN AVE
Mailing Address - Street 2:
Mailing Address - City:LAKE ORION
Mailing Address - State:MI
Mailing Address - Zip Code:48362-3330
Mailing Address - Country:US
Mailing Address - Phone:248-613-7455
Mailing Address - Fax:
Practice Address - Street 1:630 GRAMPIAN AVE
Practice Address - Street 2:
Practice Address - City:LAKE ORION
Practice Address - State:MI
Practice Address - Zip Code:48362-3330
Practice Address - Country:US
Practice Address - Phone:248-613-7455
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-22
Last Update Date:2018-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704253396163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse