Provider Demographics
NPI:1134974371
Name:MITCHELL, SHANNON DOMINIQUE (RN, BSN)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:DOMINIQUE
Last Name:MITCHELL
Suffix:
Gender:F
Credentials:RN, BSN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18068 WEXFORD ST
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48234-1852
Mailing Address - Country:US
Mailing Address - Phone:313-319-6727
Mailing Address - Fax:
Practice Address - Street 1:426 N INGALLS ST
Practice Address - Street 2:
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48109-2003
Practice Address - Country:US
Practice Address - Phone:313-319-6727
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-22
Last Update Date:2024-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704344432163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse