Provider Demographics
NPI:1255997755
Name:NUNLEY, SHVAUGHN LANIECE
Entity type:Individual
Prefix:MRS
First Name:SHVAUGHN
Middle Name:LANIECE
Last Name:NUNLEY
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 1:15445 SAINT MARYS ST
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48227-1927
Mailing Address - Country:US
Mailing Address - Phone:313-310-5674
Mailing Address - Fax:
Practice Address - Street 1:18422 W MCNICHOLS RD
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48219
Practice Address - Country:US
Practice Address - Phone:313-208-3407
Practice Address - Fax:313-209-4533
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-10
Last Update Date:2020-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MI68011062331041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program