Basic Information
| Provider Information | |||||||||
| NPI: | 1073869590 | ||||||||
| EntityType: | 1 | ||||||||
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| LastName: | WHITE | ||||||||
| FirstName: | SHAMELLE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 100 MICHIGAN ST NE | ||||||||
| Address2: | MC 845 | ||||||||
| City: | GRAND RAPIDS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 495032560 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 330 BARCLAY AVE NE | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | GRAND RAPIDS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 495032556 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6163918810 | ||||||||
| FaxNumber: | 6163918897 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/02/2012 | ||||||||
| LastUpdateDate: | 02/22/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 02/22/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 4301101356 | MI | Y | Allopathic & Osteopathic Physicians | Pediatrics |
No ID Information.