Provider Demographics
NPI:1982269320
Name:WHITESIDE, SHAANA
Entity Type:Individual
Prefix:
First Name:SHAANA
Middle Name:
Last Name:WHITESIDE
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 1:33423 WOODWARD AVE
Mailing Address - Street 2:
Mailing Address - City:BIRMINGHAM
Mailing Address - State:MI
Mailing Address - Zip Code:48009-0907
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:33423 WOODWARD AVE
Practice Address - Street 2:
Practice Address - City:BIRMINGHAM
Practice Address - State:MI
Practice Address - Zip Code:48009-0907
Practice Address - Country:US
Practice Address - Phone:248-480-4336
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-01
Last Update Date:2019-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1744P3200XOther Service ProvidersSpecialistProsthetics Case Management