Provider Demographics
NPI:1184991713
Name:KONIECZKI, SHANNON (RN, MSN, CPNP)
Entity type:Individual
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First Name:SHANNON
Middle Name:
Last Name:KONIECZKI
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Gender:F
Credentials:RN, MSN, CPNP
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Mailing Address - Street 1:4201 ST. ANTIONE UHC 5D
Mailing Address - Street 2:UNIVERDITY PEDIATRICIANS
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48201-2119
Mailing Address - Country:US
Mailing Address - Phone:313-966-5051
Mailing Address - Fax:313-966-0665
Practice Address - Street 1:3901 BEAUBIEN ST.
Practice Address - Street 2:CHILDREN'S HOSPITAL OF MI
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48201-2119
Practice Address - Country:US
Practice Address - Phone:313-993-2950
Practice Address - Fax:313-745-5237
Is Sole Proprietor?:No
Enumeration Date:2011-11-28
Last Update Date:2013-03-27
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Provider Licenses
StateLicense IDTaxonomies
MI4704261113363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics