Provider Demographics
NPI:1205119039
Name:SHAHOLLI, DANIELLE MARIE (PA-C)
Entity type:Individual
Prefix:
First Name:DANIELLE
Middle Name:MARIE
Last Name:SHAHOLLI
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1301 MERCY DR
Mailing Address - Street 2:
Mailing Address - City:MUSKEGON
Mailing Address - State:MI
Mailing Address - Zip Code:49444-1837
Mailing Address - Country:US
Mailing Address - Phone:231-739-9492
Mailing Address - Fax:231-739-8932
Practice Address - Street 1:1301 MERCY DR
Practice Address - Street 2:
Practice Address - City:MUSKEGON
Practice Address - State:MI
Practice Address - Zip Code:49444-1837
Practice Address - Country:US
Practice Address - Phone:231-739-9492
Practice Address - Fax:231-739-8932
Is Sole Proprietor?:No
Enumeration Date:2011-09-28
Last Update Date:2014-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601006207363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant