Provider Demographics
NPI:1801683347
Name:GREWAL, SHANNON KIRAN
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:KIRAN
Last Name:GREWAL
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:56424 ASHBROOKE DR W
Mailing Address - Street 2:
Mailing Address - City:SHELBY TOWNSHIP
Mailing Address - State:MI
Mailing Address - Zip Code:48316-5522
Mailing Address - Country:US
Mailing Address - Phone:951-642-1532
Mailing Address - Fax:
Practice Address - Street 1:56424 ASHBROOKE DR W
Practice Address - Street 2:
Practice Address - City:SHELBY TOWNSHIP
Practice Address - State:MI
Practice Address - Zip Code:48316-5522
Practice Address - Country:US
Practice Address - Phone:951-642-1532
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-04-21
Last Update Date:2025-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program