Provider Demographics
NPI:1255730057
Name:TANKERSLEY, SHAVONNE
Entity type:Individual
Prefix:
First Name:SHAVONNE
Middle Name:
Last Name:TANKERSLEY
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 1:1588 LONDON AVE
Mailing Address - Street 2:
Mailing Address - City:LINCOLN PARK
Mailing Address - State:MI
Mailing Address - Zip Code:48146-3522
Mailing Address - Country:US
Mailing Address - Phone:313-740-0590
Mailing Address - Fax:
Practice Address - Street 1:1588 LONDON AVE
Practice Address - Street 2:
Practice Address - City:LINCOLN PARK
Practice Address - State:MI
Practice Address - Zip Code:48146-3522
Practice Address - Country:US
Practice Address - Phone:313-740-0590
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-08-18
Last Update Date:2014-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4703111700164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse